Cedars-Sinai

Clinical Documentation Specialist II - 8 Hour Days

Cedars-Sinai • $80K — $95K *
Los Angeles, CA 90011In-Person
Healthcare
Less than 5 years of experience
Today
Be an Early Applicant
Job Overview by Ladders

Qualifications

  • High School Diploma/GED required; Associate Degree or Clinical Degree preferred.
  • Minimum of 2 years in CDI reviews in acute care or bedside experience.
  • Preferred 3 years of experience in utilization review, coding, or case management.
  • Must possess a state RN license upon hire.
  • Certification as a Clinical Documentation Specialist (CCDS), Registered Health Information Administrator (RHIA), or Clinical Documentation Integrity Practitioner (CDIP) required.

Responsibilities

  • Review and analyze clinical information for gaps in documentation in electronic health records.
  • Formulate clarifications to enhance principal diagnosis and co-morbidities documentation.
  • Confirm and assign a working DRG based on coding rules and follow up as needed.
  • Extract data for reporting on core measures and patient safety indicators.
  • Engage with physicians to clarify documentation and improve specificity.
  • Conduct post-discharge reviews for CDI and coding accuracy.
  • Communicate with the multidisciplinary care team to ensure comprehensive medical record documentation.
  • Identify documentation trends and provider-specific concerns.

Benefits

  • Opportunity for mentorship and professional development.
  • Engagement in special CDI projects for process improvement.
  • Exposure to leadership through feedback and presentation opportunities.
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 Certification

  • RN State License - Upon Hire minimum
  • Certified Clinical Documentation Specialist (CCDS)
  • Registerd Health Info Admin - (RHIA)
  • 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.
Learn more about Cedars-Sinai
Size
13,000 employees
Industry
Healthcare
Founded
1902
* Ladders Estimates

Similar Jobs

Ad banner background

Get Ready For Your
Next Interview

More Jobs at Cedars-Sinai

More Healthcare Jobs

Find similar Clinical Documentation Specialist II - 8 Hour Days jobs:

NationwideLos Angeles, CA