CDS

Prime Healthcare•Chicago, IL

1d•Onsite

About The Position

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 54 hospitals and has more than 360 outpatient locations in 15 states providing more than 3.0 million patient visits annually. It is one of the nation’s leading health systems with over 60,000 employees and physicians. Twenty-one 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! The Clinical Documentation Specialist (CDS) is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records. This review is to evaluate that the clinical documentation is reflective of quality-of-care outcomes and reimbursement compliance for acute care services provided. The CDS will work 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.

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.
Current BCLS (AHA) certificate upon hire and maintain current.
ACLS

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.

Responsibilities

Conducting clinically based concurrent and retrospective reviews of inpatient medical records.
Evaluating that the clinical documentation is reflective of quality-of-care outcomes and reimbursement compliance for acute care services provided.
Working 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.