Job Description

#Other
The Clinical Documentation Specialist (CDS) leverages extensive clinical experience and knowledge to ensure comprehensive and accurate clinical documentation in medical records. This role involves thorough record review and interaction with physicians, allied health professionals, health information management professionals, and nursing staff. The CDS supports the organization by utilizing a concurrent review process to enhance the severity of illness depiction and quality within medical records.

This includes ensuring MS-DRG classification aligns with regulatory compliance established by the Centers for Medicare and Medicaid Services (CMS). The process applies to all Medicare Fee for Service (FFS) patients and any other payers identified by the organization, adhering to all relevant coding and compliance regulations. Case review prioritization is determined by the organization and may also involve reviewing records for documentation accuracy related to APR-DRG classification and Quality Data elements, such as Patient Safety Indicators and Readmissions.

*Qualifications*
* IMG with a medical degree or RN license
* 2-3 years of Clinical Documentation Specialist (CDS) experience
* Experience in OBGYN, Pediatrics, and Inpatient Psychiatry is preferred
* Familiarity with quality-based reviews, mortality reviews, and risk adjustment tools is preferred
* Strong communication skills and ability to work well in a remote team setting

*Requirements*
* At least 2 years of CDI experience in a complex acute care setting

*Responsibilities*
* Review and analyze clinical documentation for accuracy and completeness in inpatient settings, focusing on Ob/Gyn, Psychiatry, and Pediatrics.
* Ensure compliance with HIPAA regulations while maintaining patient confidentiality.
* Collaborate with healthcare providers to improve clinical documentation practices and enhance patient care.
* Utilize EHR systems to manage medical records and facilitate documentation improvement initiatives.
* Provide training and support to staff on proper medical terminology and documentation standards.

Job Type: Full-time

Pay: $53.00 - $57.00 per hour

Schedule:
* Day shift

Application Question(s):
* do you have IMG with a medical degree or RN license ?

Experience:
* Clinical Documentation Specialist (CDS): 2 years (Preferred)

Work Location: In person

Job Tags

Hourly pay, Full time, Day shift,

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