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Clinical Documentation Specialist - 8 Hour Days

Cedars-Sinai869 open roles

Where
Los Angeles, CA, United States
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Your applicationOpen nowClinical Documentation Specialist - 8 Hour DaysCedars-Sinai · Los Angeles, CA, United States

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The clock on this job

Early applications get read.

12.9% of postings close within 7 days. Measured by our own scanner across the market. Cedars-Sinai postings stay open a median of 13 days.

Share of postings closed within
  1. 2.2%1 day
  2. 4.7%3 days
  3. 12.9%7 days
  4. 21.0%14 days
  5. 35.6%30 days
  6. 58.5%60 days
This job: posted yesterday

Cedars-Sinai median: 13 days open

The posting

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)
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