Cedars-Sinai

Clinical Documentation Specialist II - 8 Hour Days **HYBRID**

Cedars-Sinai • $75K — $95K *
Los Angeles, CA 90011Hybrid
Healthcare
5 - 7 years of experience
1 month ago
Job Overview by Ladders

Qualifications

  • High school diploma or GED required
  • Bachelor's Degree in Nursing or advanced health care field preferred
  • Foreign trained MDs will be considered
  • Relevant certification required (e.g., RHIT, RHIA, CCDS, CDIP, CPC)
  • Minimum of 5 years in Acute Clinical Care, Utilization Review, Coding, or Case Management
  • Understanding of Joint Commission standards and regulatory requirements needed
  • Broad clinical knowledge of disease processes required

Responsibilities

  • Reviews clinical information to identify documentation gaps
  • Formulates documentation clarifications for diagnosis and quality measures
  • Confirms working DRG and severity level as per coding guidelines
  • Extracts data for reporting relating to core measures and revenue optimization
  • Engages with physicians to improve documentation specificity
  • Conducts post discharge reviews for documentation integrity
  • Communicates with care team to ensure comprehensive medical record documentation
  • Identifies trends in documentation issues and provider concerns
  • Presents to peers on clinical diagnoses and regulatory updates
  • Mentors Clinical Documentation Specialist Level 1 and initiates CDI projects

Benefits

  • Opportunities for professional development and advancement
  • Supportive working environment
  • Engagement in special projects
  • Collaborative team atmosphere
  • Mentorship programs available
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 or GED required
  • Bachelor's Degree in Nursing or other advanced health care field preferred
  • Foreign trained MDs will be considered


License/Certifications:

  • Registered Nurse, LVN, Occupational Therapist, Physical Therapist, Physician Assistant, foreign MD license or certification in Health Information Management or Medical Coding, such as RHIT, RHIA, CCDS, CDIP OR CPC, required


Experience:

  • A minimum of 5 years of experience in Acute Clinical Care, Utilization Review, Coding, or Case Management required
  • Working knowledge of Joint Commission standards and regulatory requirements required
  • Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes required
  • Solid computer proficiency required

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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