CDS

Prime Healthcare Management Inc • Ontario, CA

2d • $28 - $49

About The Position

The Clinical Documentation Specialist (CDS) is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records. These reviews are to evaluate whether the clinical documentation is reflective of the quality-of-care outcomes and reimbursement compliance for acute care services provided. The CDS works closely with the medical staff to facilitate appropriate clinical documentation of patient care. Other responsibilities include conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings. He/She will perform other duties as assigned or required.

Requirements

• Medical Graduate, PA or Nursing Graduate.
• Minimum of one (1+) years clinical experience in an acute care setting in any capacity.
• Knowledge of care delivery documentation systems and related medical record documents.
• Knowledge of age-specific needs and the elements of disease processes and related procedures.
• Strong broad-based clinical knowledge and understanding of pathology / physiology of disease processes.
• Excellent written and verbal communication skills. Excellent critical thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff.

Nice To Haves

• ECFMG Certificate or RN license preferred.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment.
• Computer literacy and familiarity with the operation of basic office equipment.
• Assertive personality traits to facilitate ongoing physician communication.
• Working knowledge of Medicare reimbursement system and coding structures.
• Current BCLS (AHA) certificate upon hire and maintain current.
• ACLS

Responsibilities

• Conduct clinically based concurrent and retrospective reviews of inpatient medical records.
• Evaluate whether the clinical documentation is reflective of the quality-of-care outcomes and reimbursement compliance for acute care services provided.
• Work closely with the medical staff to facilitate appropriate clinical documentation of patient care.
• Conduct documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings.
• Perform other duties as assigned or required.

Benefits

• Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs.
• Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options.
• A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $28.00 to $48.61.
• The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees