CDS (SMKIL) - PHMI Medical Records

Prime Healthcare Management Inc • Kankakee, IL

1d • $28 - $43

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. Additional responsibilities include reviewing documentation for inpatient admission criteria, conducting initial and extended-stay concurrent reviews on selected admissions, and documenting findings.

Requirements

• Medical graduate, PA graduate, or nursing graduate.
• At least one year of 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, 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 skills.
• Excellent critical-thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nursing staff, and hospital management staff.

Nice To Haves

• ECFMG Certificate or RN license.
• 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.
• Working knowledge of the Medicare reimbursement system and coding structures.
• Current BCLS (AHA) certificate upon hire and maintained current.
• ACLS.

Responsibilities

• Conduct clinically based concurrent and retrospective 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.
• Review documentation for inpatient admission criteria.
• Conduct initial and extended-stay concurrent reviews on selected admissions.
• Document review findings.

Benefits

• Paid time off.
• 401(k) retirement plan.
• Medical coverage.
• Dental coverage.
• Vision coverage.
• Tuition reimbursement.
• Voluntary benefit options.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level