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Form of workPay range: $49.27/hr - $66.51/hr
POSITION SUMMARY:
The Clinical Documentation Specialist (CDS) is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness. This involves extensive record review, interaction with physicians, clinical staff, and HIM professionals. Utilizing advanced clinical knowledge the CDS role requires the ability to review the medical record accurately and timely, recognize opportunities for documentation improvements, formulate clinically credible documentation clarifications, follow-up timely on all cases, especially those requiring Clinical Documentation clarifications, and communicate effectively and appropriately with the physicians. The CDS participates in the Task Force Meetings, and collaborates on developing education for medical staff.
EDUCATION / TRAINING / EXPERIENCE:
Minimum:
* Five years inpatient acute care nursing experience
Desired:
* Clinical Documentation Improvement (CDI) experience
* Critical Care experience
* Bachelor's or Master's degree in nursing
* Experience in hospital operations, management and physician relations
LICENSES / CERTIFICATIONS:
Minimum:
* Current licensure with the California Board of Registered Nursing
* Current CPR certification
SKILLS / KNOWLEDGE / ABILITIES:
Must have excellent communication skills and be able to maintain strong, positive working relationships with physicians. Understands and supports the CDMP documentation strategies. Demonstrates critical thinking, problem solving, and deductive reasoning skills. Demonstrates organizational, analytical and interpersonal skills. Demonstrates evidence of being highly confidential, dependable, and self directed. Demonstrates ability to interact with a wide variety of individuals, and handle multiple priorities. Proficient in the use of multiple computer software programs; Microsoft Word, Excel, and Internet access . Knowledge of accreditation and external agency requirements. Knowledge of Medicare Part A and B and how they impact DRG assignments. Must be able to perform the essential functions of the position.
