Clinical Documentation Specialist - 8 Hour Days at Cedars-Sinai

, California, United States -

Full Time

Start Date

Immediate

Expiry Date

04 Aug, 26

Salary

82.4

Posted On

06 May, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Clinical Documentation Improvement, Medical Coding, DRG Assignment, Physician Querying, Electronic Health Records, Clinical Analysis, Patient Safety Indicators, Core Measures, Medical Auditing, Mentoring, Regulatory Compliance, Case Management

Industry

Hospitals and Health Care

Description

Summary: 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. Principal 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. Department Specific Responsibilities: Teamwork/Customer Relations Responsibilities: * Collaborates to problem solve and make decisions to achieve desired outcomes * Establishes effective working relationships with cross-functional team(s) * Responds timely, effectively and appropriately to deliverables * Shares knowledge, time and expertise to assist other members of the team * Cultivates and maintains strong customer relationships and rapport with stakeholders and/or client groups * Ensures practices and procedures are inclusive of interpersonal and cultural diversity * Identifies and responds appropriately to both internal and external customer needs utilizing available resources * Represents the company with external constituents

Responsibilities

The Clinical Documentation Specialist reviews electronic health records to identify documentation gaps and collaborates with physicians to improve diagnostic specificity. They are also responsible for mentoring Level 1 specialists and analyzing trends to optimize revenue and quality reporting.