Non-Clinical – Health and Information Management/Clinical Document Improvement Specialist

US, CA
1

Job 
Detail

Shift: Day 5×8-Hour (08:30 – 17:00)
Day 5×8-Hour (07:00 – 18:30)

Description:

Shift: 5 x 8 Days, start times from 0700-8:30 rotating, around 50% onsite and 50% remote

Job Description: The Clinical Documentation Specialist (CDS) uses strong clinical experience and knowledge to facilitate complete and specific clinical documentation in the medical record, reflecting the patient’s accurate clinical picture. This involves extensive record review, interaction with physicians, allied health professionals, health information management professionals, and nursing staff. The CDS assists the organization by utilizing a concurrent review process to promote optimized severity of illness and quality in the medical record. This includes MS-DRG classification according to regulatory compliance set forth by Centers for Medicare and Medicaid Services (CMS). This process will be applied to all Medicare Fee for Service (FFS) patients as well as any other payers identified by the organization in a manner consistent with all pertinent coding and compliance regulations. Case review prioritization is based on the prioritization by the organization and may also include review of records for accuracy of documentation related to APR-DRG classification and Quality Data elements (e.g. Patient Safety Indicators, Readmissions, etc.).

Requirements:
1. At least 2 years of CDI experience in a complex acute care setting.

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