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
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Job Overview by Ladders

Qualifications

  • High School Diploma/GED required; Associate Degree/College Diploma in Nursing, Health Information, or Foreign Medical Graduate preferred.
  • Minimum of 2 years performing CDI reviews in an acute care setting.
  • Preferred 3 years of experience in utilization review, coding, or case management.
  • Certification required as Certified Clinical Documentation Specialist (CCDS).
  • Licensure as Registered Health Info Admin (RHIA) or Clinical Documentation Integrity Practitioner (CDIP) is preferred.

Responsibilities

  • Review and analyze clinical information in electronic health records for documentation gaps.
  • Formulate clarifications to improve accuracy in principal diagnosis and quality core measures documentation.
  • Confirm and assign diagnostic related group (DRG) and severity level based on coding guidelines.
  • Extract essential data for reporting and tracking, focusing on Joint Commission, CORE measures, and revenue optimization.
  • Engage in ongoing communication with physicians to enhance documentation specificity.
  • Conduct post-discharge reviews for clinical documentation integrity compared to coding records.
  • Identify trends in documentation issues and conduct presentations on relevant topics.

Benefits

  • Opportunities for professional development and certifications.
  • Mentorship experience within the healthcare team.
  • Engagement in special projects for process improvement.
  • Collaboration with a multidisciplinary care team.
  • Contribution to enhancing patient safety and quality of care.
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
  • Certified Clinical Documentation Specialist (CCDS)
  • Registered 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

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