Specialist - Clinical Document PD Days

AHMC Healthcare • Monterey Park, CA

2d

About The Position

JOB SUMMARY: The Clinical Documentation Specialist (CDS) is responsible conducting clinically based clinical 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 RN with current valid license and relevant education.
• CCS Certification required.
• Minimum of 3+ years clinical experience in an acute care setting.
• 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.
• 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.
• Current BCLS (AHA) certificate upon hire and maintain current

Nice To Haves

• Prior Case Management experience is desirable.
• Working knowledge of Medicare reimbursement system and coding structures preferred.
• ACLS preferred.

Responsibilities

• Conducting clinically based clinical Concurrent and retrospective reviews of inpatient medical records.
• Evaluate that the clinical documentation is reflective of quality of care outcomes and reimbursement compliance for acute care services provided.
• Work 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.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees