High School Diploma/GED required; Associate Degree in Nursing, Health Information, or foreign medical degree preferred.
Minimum of 2 years performing Clinical Documentation Integrity (CDI) reviews in an acute care setting.
Preferred 3 years of experience in utilization review, coding, or case management.
Certification as a Clinical Documentation Specialist (CCDS) or equivalent required upon hire.
Active RN State License or Registered Health Information Administrator (RHIA) required upon hire.
Responsibilities
Review and analyze clinical information in electronic health records to identify documentation gaps.
Formulate clarifications to enhance clinical documentation of diagnoses and quality measures.
Confirm and assign diagnostic related groups (DRGs) and severity levels based on coding guidelines.
Extract data for reporting on Joint Commission reviews and patient safety indicators.
Engage with physicians to clarify and improve documentation specificity.
Conduct post-discharge reviews for comparative analysis of documentation integrity.
Communicate with healthcare team members to ensure comprehensive medical record documentation.
Benefits
Mentorship opportunities for professional development.
Engagement in special clinical documentation integrity projects.
Access to ongoing training and presentations on regulatory changes and best practices.
Full Job Description
Job Description
The Clinical Documentation Specialist (CDS) II is a more experienced CDS, spending at least 75% of their time on independent reviews without supervision, creating queries, and facilitating their follow-up. Level 2 specialists create trend reports to provide insights into documentation practices and engage directly with physicians to manage queries. They spend 25% of their time mentoring the CDS I and providing feedback to leadership.
Responsibilities
Reviews and analyzes clinical information with the electronic health record to identify areas within the chart for potential gaps in physician/provider documentation.
Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI).
Confirms and/or assigns a working diagnostic related group (DRG) and severity level using coding rules and guidelines with follow up reviews as required by length of stay (LOS) standards.
Extracts essential data elements for reporting and tracking, specifically for Joint Commission record reviews, CORE measures, severity of illness (SOI)/risk of mortality (ROM) assessments, patient safety indicators (PSI), and revenue optimization criteria, dedicating full attention to core measure responsibilities.
Engages in ongoing queries with physicians and providers to clarify and enhance documentation specificity in medical records.
Conducts post discharge reviews for comparative analysis clinical documentation integrity (CDI) and Coding assigned codes.
Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.
Identifies trends related to documentation issues, provider specific concerns, code specific needs, etc.
Makes presentations to peer audiences on various topics, such as clinical diagnoses, regulatory changes, guidelines, new practices, etc.
Mentors and precepts Clinical Documentation Specialist Level 1. Initiates special clinical documentation integrity (CDI) projects for process improvement.
Qualifications
Education
High School Diploma/GED - minimum
Assoc. Degree/College Diploma Clinical Degree - Nursing, Health Information or Foreign Trained Medical graduate. - preferred
Experience
2 years Performing CDI reviews within an acute care facility or bedside experience - minimum
3 years Utilization review, coding or case management experience - preferred
Licenses and Certifications
- Upon Hire minimum -OR- Certified Clinical Documentation Specialist (CCDS)
RN State License - Upon Hire minimum -OR- (Does not need to be CA)
Registerd Health Info Admin - Upon Hire minimum -OR- (RHIA)
- Upon Hire minimum -OR- Clinical Documentation Integrity Practitioner (CDIP)
About Cedars-Sinai
Cedars-Sinai is a non-profit academic medical center located in Los Angeles, California. It is one of the largest hospitals in the United States, with over 1,000 beds and 2,000 physicians. Cedars-Sinai is known for its high-quality patient care, cutting-edge research, and innovative medical education programs. The hospital has been ranked as one of the best in the country by U.S. News & World Report, and has received numerous awards and accolades for its clinical excellence and research achievements. Cedars-Sinai is affiliated with the David Geffen School of Medicine at UCLA and is a member of the Cedars-Sinai Health System.
