St Francis Medical Center

Clinical Documentation Specialist (CDS)

St Francis Medical Center$75K — $90K *
Hospitals & Medical Centers
Less than 5 years of experience
Job Overview by Ladders

Qualifications

  • Medical Graduate, PA or Nursing Graduate
  • At least one year of clinical experience in an acute care environment
  • Familiar with care delivery documentation systems
  • Knowledge of age-specific needs and disease processes
  • Strong clinical knowledge regarding pathology/physiology
  • Excellent communication and critical thinking skills
  • Strong interpersonal abilities for collaboration with healthcare professionals
  • Independently capable in a fast-paced setting

Responsibilities

  • Conduct concurrent and retrospective reviews of inpatient medical records
  • Ensure clinical documentation matches quality-of-care standards and reimbursement compliance
  • Collaborate with medical staff to improve clinical documentation
  • Perform inpatient admission criteria documentation
  • Carry out initial and extended-stay reviews for selected admissions
  • Document findings from medical record reviews
  • Perform additional duties as required

Benefits

  • Competitive compensation and comprehensive benefits package
  • Flexibility to tailor benefits to individual needs
  • Paid time off
  • 401K retirement plan
  • Medical, dental, and vision coverage
  • Tuition reimbursement
  • Various voluntary benefit options
Full Job Description
Overview

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

EDUCATION, EXPERIENCE, TRAINING

 

Required Qualifications:

  • Medical Graduate, PA or Nursing Graduate
  • Minimum of 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.
  •  

    Preferred Qualifications:

  • ECFMG Certificate or RN license
  • Prior Case Management Experience
  • Working knowledge of the Medicare reimbursement system and coding structures   
  • Current BCLS (AHA) certificate upon hire and maintain current.
  • ACLS Certificate
  • Pay Transparency

    Centinela Hospital Medical Center offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $XX.00 to $XX.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.

    Employment StatusFull Time ShiftDays

    About St Francis Medical Center

    St. Francis Medical Center is a for-profit hospital in Lynwood, California, United States, owned by Prime Healthcare Services.
    Learn more about St Francis Medical Center

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