Registered Nurse - Clinical Documentation Specialist - 8 Hour Days

Cedars-Sinai • Los Angeles, CA

13h

About The Position

The Clinical Documentation Specialist (CDS) II is a more experienced CDS, spending at least 75% of their time on independent reviews without supervision, creating queries, and facilitating their follow-up. Level 2 specialists create trend reports to provide insights into documentation practices and engage directly with physicians to manage queries. They spend 25% of their time mentoring the CDS I and providing feedback to leadership.

Requirements

• Registered Nurse
• Clinical Documentation Specialist experience

Nice To Haves

• Experience mentoring CDS I
• Experience providing feedback to leadership
• Experience creating trend reports
• Experience managing queries
• Experience with Joint Commission record reviews
• Experience with CORE measures
• Experience with severity of illness (SOI)/risk of mortality (ROM) assessments
• Experience with patient safety indicators (PSI)
• Experience with revenue optimization criteria
• Experience with clinical documentation integrity (CDI)
• Experience with coding assigned codes
• Experience with physician/provider communication
• Experience with nurse practitioner communication
• Experience with case manager communication
• Experience with coder communication
• Experience with care team communication
• Experience with problem-solving
• Experience with decision-making
• Experience establishing effective working relationships
• Experience responding timely, effectively and appropriately to deliverables
• Experience sharing knowledge, time and expertise
• Experience cultivating and maintaining strong customer relationships and rapport
• Experience ensuring practices and procedures are inclusive of interpersonal and cultural diversity
• Experience identifying and responding appropriately to internal and external customer needs
• Experience representing the company with external constituents

Responsibilities

• Reviews and analyzes clinical information with the electronic health record to identify areas within the chart for potential gaps in physician/provider documentation.
• Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI).
• Confirms and/or assigns a working diagnostic related group (DRG) and severity level using coding rules and guidelines with follow up reviews as required by length of stay (LOS) standards.
• Extracts essential data elements for reporting and tracking, specifically for Joint Commission record reviews, CORE measures, severity of illness (SOI)/risk of mortality (ROM) assessments, patient safety indicators (PSI), and revenue optimization criteria, dedicating full attention to core measure responsibilities.
• Engages in ongoing queries with physicians and providers to clarify and enhance documentation specificity in medical records.
• Conducts post discharge reviews for comparative analysis clinical documentation integrity (CDI) and Coding assigned codes.
• Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.
• Identifies trends related to documentation issues, provider specific concerns, code specific needs, etc.
• Makes presentations to peer audiences on various topics, such as clinical diagnoses, regulatory changes, guidelines, new practices, etc.
• Mentors and precepts Clinical Documentation Specialist Level 1. Initiates special clinical documentation integrity (CDI) projects for process improvement.
• Collaborates to problem solve and make decisions to achieve desired outcomes
• Establishes effective working relationships with cross-functional team(s)
• Responds timely, effectively and appropriately to deliverables
• Shares knowledge, time and expertise to assist other members of the team
• Cultivates and maintains strong customer relationships and rapport with stakeholders and/or client groups
• Ensures practices and procedures are inclusive of interpersonal and cultural diversity
• Identifies and responds appropriately to both internal and external customer needs utilizing available resources
• Represents the company with external constituents

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees