Clinical Documentation Sp

PIONEERS MEMORIAL HEALTHCARE DISTRICT•Brawley, CA

11d•$35 - $41

About The Position

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

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
Familiar with Medicare Part B
General understanding of hospital based Quality initiatives (training provided)
Knowledge of regulatory environment
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
Graduation from a program of nursing, BSN, preferred.
Current California Registered Nurse license required
Current American Heart Association CPR required.

Responsibilities

Learn/develop the skills necessary to perform CDMP®
Accurate and timely record review
Recognize opportunities for documentation improvement
Formulate clinically credible documentation clarifications
Effective and appropriate communication with physicians
Timely follow up on all cases especially those with clinical documentation clarifications
Participate in Task Force Meetings
Communicates with HIM staff and resolves discrepancies
Accurate input of data into CDMP Trak®
Manage multiple priorities
Performs other duties as assigned.