CDS

Prime Healthcare•Ontario, CA

14h•$28 - $49

About The Position

Overview Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 51 hospitals and has more than 360 outpatient locations in 14 states providing more than 2.5 million patient visits annually. It is one of the nation’s leading health systems with nearly 57,000 employees and physicians. Eighteen of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team! Responsibilities 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

conducting 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
works closely with the medical staff to facilitate appropriate clinical documentation of patient care
conducting 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