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$35/hr–$41/hr
Full-time
bachelor degree
Posted 8h ago
~40 hrs/week
Responsibilities
The Clinical Documentation Specialist reviews medical records to ensure the accurate representation of patient illness severity. This role involves collaborating with physicians and HIM professionals to clarify documentation and educate staff on CDMP processes.
Requirements
Candidates must be a Registered Nurse licensed in California with current AHA CPR certification. Preferred qualifications include a BSN and recent hospital experience in ICU, CCU, or Med/Surg units.
Full job description
SUMMARY:
The CDS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness. This involves extensive record review, interaction with physicians, Health Information Management professionals, and nursing staff. Active participation in team meetings and education of staff in the CDMP® process is a key role.
ESSENTIAL FUNCTIONS:
Job functions reflect the following objectives:
Ability to learn/develop the skills necessary to perform CDMP®
Accurate and timely record review
Recognize opportunities for documentation improvement
Effective and appropriate communication with physicians
Timely follow up on all cases especially those with clinical documentation clarifications
Participate in Task Force Meetings
Communicates with HIM staff and resolves discrepancies
Accurate input of data into CDMP Trak®
OTHER RESPONSIBILITIES:
Manage multiple priorities
Performs other duties as assigned.
KNOWLEDGE, SKILLS, ABILITIES, AND EXPERIENCE REQUIRED:
Organizational, analytical, writing and interpersonal skills
Dependable, self directed and pleasant
Critical thinking, problem solving and deductive reasoning skills
Recent hospital experience preferably ICU, CCU, or strong Med/Surg.
Knowledge of Pathophysiology and Disease Process
Basic Computer skills – familiarity with Windows based software programs
Knowledge of Medicare Part A
Familiar with Medicare Part B
General understanding of hospital based Quality initiatives (training provided)
Knowledge of regulatory environment
Understand and support CDMP® documentation strategies (upon completion of training)
Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments
LICENSES AND CERTIFICATIONS:
Graduation from a program of nursing, BSN, preferred.
Current California Registered Nurse licenserequired
Current American Heart Association CPR required.
AGE OF POPULATION SERVED:
Newborn Infant/Pediatric Adolescent Adult Geriatric All No Patient Care
Related keywords
Clinical Documentation ImprovementCDMPCDMP TrakMedical RecordsHIMMedicare Part AMedicare Part BDRGBSNRegistered NurseRNCPRPathophysiologyICUCCUMed/Surg
Pioneers Memorial Healthcare District, an Affiliate of the Scripps Health Network is proud to be the only ISO 9000:2008 certified hospital in the County of Imperial. ISO 9000:2008 certification is an international signal of our dedication and commitment to protecting our patients’ health and safety while they are with us.
Located in Southern California, Pioneers Memorial Hospital is a highly recognized, 107-bed, acute care facility accredited by DNV - which stands for Det Norske Veritas – the Nordic Truth, is a hospital accreditation organization approved by the U. S. Center for Medicare and Medicaid (CMS) and has some of the most strenuous standards in healthcare. We are committed to providing state-of-the-art healthcare and the highest quality community education. Located in Imperial Valley in southeastern California, Pioneers opened our doors in 1950. From the very beginning, we have been committed to continually updating, upgrading and improving our facility and our care. We have invested in technological advancements not commonly found in a hospital of our size. We offer a modern 16-bed emergency facility. We are a level 4 trauma center with an excellent reputation and board-certified emergency physicians. We offer specialized treatment through our Cancer Institute, Wound Clinic, Joint Replacement, Physical Therapy Center, Pioneers Health Center and Calexico Health Center. Within the Phyllis Dillard Family Medical Center is a duo surgery suite for obstetrical and gynecological surgeries. There are 14 suites in our Perinatal Department within the Women’s Center and we deliver approximately 1,800 babies per year.
Pioneers Memorial Healthcare District, an Affiliate of the Scripps Health Network is proud to be the only ISO 9000:2008 certified hospital in the County of Imperial. ISO 9000:2008 certification is an international signal of our dedication and commitment to protecting our patients’ health and safety while they are with us.
Located in Southern California, Pioneers Memorial Hospital is a highly recognized, 107-bed, acute care facility accredited by DNV - which stands for Det Norske Veritas – the Nordic Truth, is a hospital accreditation organization approved by the U. S. Center for Medicare and Medicaid (CMS) and has some of the most strenuous standards in healthcare. We are committed to providing state-of-the-art healthcare and the highest quality community education. Located in Imperial Valley in southeastern California, Pioneers opened our doors in 1950. From the very beginning, we have been committed to continually updating, upgrading and improving our facility and our care. We have invested in technological advancements not commonly found in a hospital of our size. We offer a modern 16-bed emergency facility. We are a level 4 trauma center with an excellent reputation and board-certified emergency physicians. We offer specialized treatment through our Cancer Institute, Wound Clinic, Joint Replacement, Physical Therapy Center, Pioneers Health Center and Calexico Health Center. Within the Phyllis Dillard Family Medical Center is a duo surgery suite for obstetrical and gynecological surgeries. There are 14 suites in our Perinatal Department within the Women’s Center and we deliver approximately 1,800 babies per year.