The Clinical Documentation Specialist (CDS) reviews medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physiciansâ clinical documentation. This involves extensive record review and interaction with physicians, Medical Records coders, case managers, and nursing staff. The CDS indirectly assures case mix index, Diagnostic Resource Group (DRG) assignment and accuracy of the physician profile data. This will be accomplished by doing concurrent review of the medical records along with query of the medical staff and other caregivers as necessary. This review may be accomplished via documentation prompters and/or verbal communication with the physician to obtain accurate and complete documentation which appropriately supports the severity of patient illness. Performs other duties as required.
Graduate from an accredited school of Nursing. Bachelorâs degree in Nursing preferred. License to practice as a Registered Nurse in the State of California. Three years of clinically well-rounded medical or surgical acute care nursing experience. Critical care nursing experience preferred. OR Associate's degree in applied sciences or related field with emphasis in healthcare. Bachelorâs degree in a related area preferred. Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist). Three years of inpatient coding experience. Clinical Documentation Specialist experience in an acute care hospital preferred. OR Graduate from an accredited medical school, either foreign or domestic, with a CCDS (Certified Clinical Documentation Specialist) credential and minimum of one year experience working as a Clinical Documentation Specialist in an acute care hospital. OR A Certified Documentation Improvement Practitioner (CDIP).
Job: Information Systems
Primary Location: Turlock, California
Facility: Emanuel Medical Center
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâs or employeeâs race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.