Clinical Documentation Specialist - 8 Hour Days

Cedars-Sinai Medical Center • Los Angeles, CA

9d

About The Position

The Clinical Documentation Specialist (CDS) II is an experienced specialist who spends at least 75% of their time conducting independent reviews without supervision, creating queries, and facilitating follow-up. Level 2 specialists develop trend reports to provide insight into documentation practices and engage directly with physicians to manage queries. They devote 25% of their time to mentoring CDS I specialists and providing feedback to leadership.

The role reviews clinical information in the electronic health record, identifies potential documentation gaps, and supports accurate and complete documentation of diagnoses, comorbidities, present-on-admission status, quality core measures, and patient safety indicators. It also confirms or assigns working DRGs and severity levels, conducts follow-up reviews as required by length-of-stay standards, extracts data for reporting and tracking, and performs post-discharge reviews comparing clinical documentation integrity and coding. The specialist works with physicians and other care-team members, identifies documentation trends, presents information to peers, mentors CDS I specialists, and initiates CDI process-improvement projects.

Requirements

• At least 2 years of CDI review experience in an acute-care facility or bedside experience.
• At least a high school diploma or GED.
• Upon hire, meet the stated minimum credential requirement through an applicable listed credential: CCDS; an RN state license (not required to be California); Registered Health Information Administrator (RHIA); or Clinical Documentation Integrity Practitioner (CDIP).

Nice To Haves

• Associate degree or college diploma in a clinical field such as nursing or health information, or foreign-trained medical graduate.
• At least 3 years of utilization review, coding, or case management experience.

Responsibilities

• Review and analyze clinical information in the electronic health record to identify potential gaps in physician or provider documentation.
• Formulate credible clinical documentation clarifications to improve documentation of principal diagnoses, comorbidities, present-on-admission status, quality core measures, and patient safety indicators.
• Confirm or assign working DRGs and severity levels using coding rules and guidelines, with follow-up reviews as required by length-of-stay standards.
• Extract essential data elements for reporting and tracking, including Joint Commission record reviews, core measures, SOI/ROM assessments, patient safety indicators, and revenue optimization criteria; give full attention to core measure responsibilities.
• Conduct ongoing queries with physicians and providers to clarify and improve documentation specificity in medical records.
• Conduct post-discharge reviews comparing clinical documentation integrity and assigned coding.
• Communicate with physicians, nurse practitioners, case managers, coders, and other care-team members to support comprehensive medical record documentation of treatment and decision-making.
• Identify trends involving documentation issues, provider-specific concerns, and code-specific needs.
• Present to peer audiences on topics such as clinical diagnoses, regulatory changes, guidelines, and new practices.
• Mentor and precept Clinical Documentation Specialist Level 1 staff.
• Initiate special CDI projects for process improvement.
• Spend at least 75% of work time on independent reviews, queries, and follow-up, and 25% mentoring CDS I staff and providing feedback to leadership.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED