Clinical Documentation Specialist

Shift: Day

Job type: Full Time

Hours:

Position Summary                        
Reporting to the Manager, CDI (Corporate), the Clinical Documentation Specialist (CDS) will be responsible for facilitating concurrent documentation of the medical record to achieve accurate inpatient coding and legitimate DRG assignment.  The initial focus will be on the Medicare population.                        
 

Minimum Experience/Skills:        

3 years clinical experience in an acute care setting OR  3 years CDI experience
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
Working knowledge of Medicare reimbursement system and coding structures desired, not required
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 
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.
 

License/Certificates/Credentials:        

Current California Registered Nurse License or CDI/CCS Certification                
 

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