Clinical Documentation Sp

PIONEERS MEMORIAL HEALTHCARE DISTRICT•Brawley, CA

10d•Onsite

About The Position

The Clinical Documentation Specialist (CDS) is responsible for reviewing medical records to ensure the accurate representation of the severity of illness. This role involves extensive record review, interaction with physicians, Health Information Management professionals, and nursing staff. Active participation in team meetings and educating staff on the CDMP® process are key components of this position.

Requirements

Organizational, analytical, writing and interpersonal skills.
Dependable, self-directed and pleasant.
Critical thinking, problem-solving and deductive reasoning skills.
Recent hospital experience, preferably ICU, CCU, or strong Med/Surg.
Knowledge of Pathophysiology and Disease Process.
Basic Computer skills – familiarity with Windows-based software programs.
Knowledge of Medicare Part A.
Familiarity with Medicare Part B.
General understanding of hospital-based Quality initiatives (training provided).
Knowledge of the regulatory environment.
Current California Registered Nurse license.
Current American Heart Association CPR required.

Nice To Haves

BSN preferred.
Understand and support CDMP® documentation strategies (upon completion of training).
Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments.

Responsibilities

Facilitate the accurate representation of the severity of illness through medical record review.
Interact extensively with physicians, Health Information Management professionals, and nursing staff.
Actively participate in team meetings.
Educate staff in the CDMP® process.
Perform accurate and timely record review.
Recognize opportunities for documentation improvement.
Formulate clinically credible documentation clarifications.
Communicate effectively and appropriately with physicians.
Follow up on all cases, especially those with clinical documentation clarifications.
Participate in Task Force Meetings.
Communicate with HIM staff and resolve discrepancies.
Accurately input data into CDMP Trak®.
Manage multiple priorities.
Perform other duties as assigned.