Clinical Documentation Specialist - 8 Hour Days
Cedars-Sinai · Los Angeles, California
What the posting says
Each fact was read from this posting and checked:Statedin the posting, quotedConflictsposted two ways, both shownNot mentionedwe looked; it is not there
- Employment typeStated
- Full time
- ExperienceStated
- 2-5 years
- EducationStated
- ['high school', 'associate degree', 'professional certificate']
Not mentioned in this posting
We read the whole posting. These are not in it. Not a no: ask the recruiter, in your own words.
- PayNot mentioned
- The posting does not say
- Work arrangementNot mentioned
- The posting does not say
- ShiftNot mentioned
- The posting does not say
- Visa sponsorshipNot mentioned
- The posting does not say
Requirements, each with its sentence from the posting
These are the employer’s words. The index does not judge whether you meet them.
- High School Diploma/GEDrequired
High School Diploma/GED - minimum
from the posting - 2 years CDI reviews in acute care or bedside experiencerequired
2 years Performing CDI reviews within an acute care facility or bedside experience - minimum
from the posting - Certified Clinical Documentation Specialist (CCDS)required
Certified Clinical Documentation Specialist (CCDS)
from the posting - RN State Licenserequired
RN State License - Upon Hire minimum
from the posting - Registered Health Information Administrator (RHIA)required
Registerd Health Info Admin - Upon Hire minimum
from the posting - Clinical Documentation Integrity Practitioner (CDIP)required
Clinical Documentation Integrity Practitioner (CDIP)
from the posting - Associate degree or Clinical Degree in Nursing, Health Information or equivalentpreferred
Assoc. Degree/College Diploma Clinical Degree – Nursing, Health Information or Foreign Trained Medical graduate. - preferred
from the posting - 3 years Utilization review, coding or case management experiencepreferred
3 years Utilization review, coding or case management experience - preferred
from the posting
Read the full posting as the employer wrote it
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.
Qualifications
Education- High School Diploma/GED - minimum
- Assoc. Degree/College Diploma Clinical Degree – Nursing, Health Information or Foreign Trained Medical graduate. - preferred
Experience
- 2 years Performing CDI reviews within an acute care facility or bedside experience - minimum
- 3 years Utilization review, coding or case management experience - preferred
Licenses and Certifications
- - Upon Hire minimum -OR- Certified Clinical Documentation Specialist (CCDS)
- RN State License - Upon Hire minimum -OR- (Does not need to be CA)
- Registerd Health Info Admin - Upon Hire minimum -OR- (RHIA)
- - Upon Hire minimum -OR- Clinical Documentation Integrity Practitioner (CDIP)
The posting text is reproduced as the employer wrote it; the index adds nothing to it.