CDS

Prime Healthcare•Chicago, IL

About The Position

The Clinical Documentation Specialist (CDS) conducts clinically based concurrent and retrospective reviews of inpatient medical records to evaluate whether clinical documentation reflects quality-of-care outcomes and reimbursement compliance for acute care services. The CDS works closely with medical staff to facilitate appropriate clinical documentation of patient care. The role also includes reviewing inpatient admission criteria, conducting initial and extended-stay concurrent reviews of selected admissions, and documenting findings. Other duties may be assigned or required.

Requirements

Medical graduate, PA graduate, or nursing graduate required.
At least one year of clinical experience in an acute care setting.
Knowledge of care-delivery documentation systems and related medical record documents.
Knowledge of age-specific needs, disease processes, and related procedures.
Strong broad-based clinical knowledge and understanding of the pathology and physiology of disease processes.
Excellent written and verbal communication, and critical-thinking skills.
Excellent interpersonal skills to build effective working relationships with physicians, nursing staff, and hospital management staff.
Working knowledge of inpatient admission criteria.
Ability to work independently in a time-oriented environment.
Computer literacy and familiarity with basic office equipment.
Assertive personality traits to facilitate ongoing physician communication.

Nice To Haves

ECFMG Certificate or RN license preferred.
Prior case management experience preferred.
Working knowledge of the Medicare reimbursement system and coding structures preferred.
Current BCLS (AHA) certificate upon hire and maintained as current preferred.
ACLS Certificate preferred.

Responsibilities

Conduct concurrent and retrospective clinical reviews of inpatient medical records.
Evaluate whether clinical documentation reflects quality-of-care outcomes and reimbursement compliance for acute care services.
Work with medical staff to facilitate appropriate clinical documentation of patient care.
Conduct documentation reviews for inpatient admission criteria.
Perform initial and extended-stay concurrent reviews on selected admissions and document findings.
Perform other duties as assigned or required.