The Clinical Documentation Specialist (CDS) II performs independent clinical documentation reviews, creates and follows up on queries, and supports documentation integrity across the care team.
- Reviews clinical information in the electronic health record to identify documentation gaps.
- Creates credible clarifications to improve documentation of diagnoses, co-morbidities, POA status, quality measures, and patient safety indicators.
- Confirms or assigns working DRGs and severity levels using coding rules and guidelines.
- Extracts and tracks data for Joint Commission reviews, CORE measures, SOI/ROM assessments, PSI, and revenue optimization.
- Conducts post-discharge reviews and compares CDI findings with coded data.
- Communicates with physicians, nurse practitioners, case managers, coders, and other care team members.
- Identifies trends in documentation issues and presents findings to peers and leadership.
- Mentors CDS I staff and supports CDI process improvement projects.
Requirements & Qualifications
- High school diploma or GED required.
- Bachelor's degree in Nursing or another advanced health care field preferred.
- Foreign trained MDs will be considered.
- CCDS required.
- 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, CDIP, or CPC preferred.
- Minimum 3 years of experience in acute clinical care, utilization review, coding, or case management preferred.
- 2 years of CDI review experience in an acute care facility or bedside experience required.
- Working knowledge of Joint Commission standards and regulatory requirements.
- Strong clinical knowledge of pathology and disease processes preferred.
- Solid computer proficiency required.
Location
Los Angeles, California, US
Employment Type
Full-time
Experience Level
Senior
Remote work allowed
No
Posted
4 weeks ago