Clinical Documentation Specialist

The Clinical Documentation Specialist performs record review (quantitative and qualitative) and assesses the level of compliance with stated regulatory requirements by area of job focus. Assigns a working MS-DRG/APR-DRG. Assists in clarifying clinical information used for measuring and reporting physician and medical center outcomes which incorporates current DRG methodologies (e.g., MS-DRGs, etc.) by CMS and/or other regulatory/quality reporting bodies (e.g. APR-DRGs, SOI, ROM, etc.). Issues queries to members of the patient care team – primarily physicians – regarding possible diagnoses or to improve the specificity of diagnoses thru enhanced clinical documentation. Facilitates modifications to clinical documentation as needed to support component stated previously. Leads or provides education/training to clinical care (physicians, nurses, etc.) and administrative support team members regarding the clinical documentation requirements essential for demonstrating quality patient care (SOI, ROM, etc.), the regulatory interpretation of outcomes for focused diagnoses, and their impact on reimbursement and quality reporting for the organization. Assists in developing educational materials as needed. Demonstrates knowledge of applicable regulatory standards/requirements by applying them accurately when providing guidance to customers. Accurately applies knowledge during record review activities. Supports ad-hoc reviews or data collection activities for focused or special research studies conducted within the organization.

• High School Diploma or GED required.
• Bachelor’s degree in nursing, health information management or a similar major preferred. A foreign medical degree may be considered.
• RN State License - Current RN license (not limited to State of California) or higher clinical degree (i.e., MD), or Registered Health Info Admin, or Registered Health Info Tech required upon hire. 
• Clinical Documentation Improvement Professional (CDIP) or Certified clinical Documentation Specialist (CCS) preferred.
• A minimum of 3 years of acute care experience required. A minimum of 3 years of experience in Utilization Review, Coding, or Case Management experience preferred.