Clinical Documentation Specialist

Reporting to the Director of Health Information Management, thisposition is responsible for facilitating concurrent documentation of themedical record to achieve accurate inpatient coding and legitimate DRGassignment.

Provide clinically based concurrent and retrospective review ofinpatient medical records to evaluate the utilization and documentation ofacute care services.

Includes facilitation of appropriate physician documentationof care to accurately reflect patient severity of illness and risk ofmortality.

This position plays a significant role in reporting quality of careoutcomes and in obtaining accurate and compliant reimbursement for acute careservices.

QUALIFICATIONS :

1. 3-5 years clinical experience in an acute care setting preferred. CaseManagement and / or coding experience a plus.

2.CCDS or CDIS certification preferred upon hire or transfer. Successful completion of CCDS or CDIP certificateexamination within three years and nine months from date of hire.

3. CDSI requires currentvalid California LVN license.

4. CDS II requires current California RN license