CDS

Responsibilities

The Clinical Documentation Specialist (CDS) is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records. These reviews are to evaluate whether the clinical documentation is reflective of the quality-of-care outcomes and reimbursement compliance for acute care services provided. The CDS works 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. He/She will perform other duties as assigned or required.

Qualifications

• Medical Graduate, PA or Nursing Graduate required
• Minimum of three one (1+) year’s 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 and 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.
• ECFMG Certificate or RN license preferred.
• Prior Case Management Experience preferred.
• Working knowledge of the Medicare reimbursement system and coding structures preferred.
• Current BCLS (AHA) certificate upon hire and maintain current preferred.
• ACLS Certificate preferred.

Employment Status: Full Time; Shift Days: (as scheduled)

Benefits

• Paid time off
• 401K retirement plan
• Medical, dental, and vision coverage
• Tuition reimbursement
• Many more voluntary benefit options

Learn more about benefits: https://www.primehealthcare.com/benefitsthatmattermost/

Pay

A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $58,240.00 to $90,272.00. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.