Clinical Documentation Specialist II - 8 Hour Days HYBRID

Cedars-Sinai Medical Center • Beverly Hills, CA

2d • Hybrid

About The Position

The Clinical Documentation Specialist (CDS) II is a more experienced CDS, spending at least 75% of their time on independent reviews without supervision, creating queries, and facilitating their follow-up. Level 2 specialists create trend reports to provide insights into documentation practices and engage directly with physicians to manage queries. They spend 25% of their time mentoring the CDS I and providing feedback to leadership.

Requirements

• High school diploma or GED required
• A minimum of 5 years of experience in Acute Clinical Care, Utilization Review, Coding, or Case Management required
• Working knowledge of Joint Commission standards and regulatory requirements required
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes required
• Solid computer proficiency required

Nice To Haves

• Bachelor's Degree in Nursing or other advanced health care field preferred
• Foreign trained MDs will be considered

Responsibilities

• Reviews and analyzes clinical information with the electronic health record to identify areas within the chart for potential gaps in physician/provider documentation.
• Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI).
• Confirms and/or assigns a working diagnostic related group (DRG) and severity level using coding rules and guidelines with follow up reviews as required by length of stay (LOS) standards.
• Extracts essential data elements for reporting and tracking, specifically for Joint Commission record reviews, CORE measures, severity of illness (SOI)/risk of mortality (ROM) assessments, patient safety indicators (PSI), and revenue optimization criteria, dedicating full attention to core measure responsibilities.
• Engages in ongoing queries with physicians and providers to clarify and enhance documentation specificity in medical records.
• Conducts post discharge reviews for comparative analysis clinical documentation integrity (CDI) and Coding assigned codes.
• Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.
• Identifies trends related to documentation issues, provider specific concerns, code specific needs, etc.
• Makes presentations to peer audiences on various topics, such as clinical diagnoses, regulatory changes, guidelines, new practices, etc.
• Mentors and precepts Clinical Documentation Specialist Level 1.
• Initiates special clinical documentation integrity (CDI) projects for process improvement.

Benefits

• Flu vaccine based on the seasonal availability of flu vaccine (typically during September through March each year) as a condition of employment, and annually thereafter as a condition of continued employment.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED