Primary Responsibilities / Accountabilities :
- The Clinical Documentation Specialist (CDS) uses strong clinical experience and knowledge to facilitate complete and specific clinical documentation in the medical record, reflecting the patient's accurate clinical picture.
- This involves extensive record review, interaction with physicians, allied health professionals, health information management professionals, and nursing staff.
- The CDS assists the organization by utilizing a concurrent review process to promote optimized severity of illness and quality in the medical record.
- This includes MS-DRG classification according to regulatory compliance set forth by Centers for Medicare and Medicaid Services (CMS).
- This process will be applied to all Medicare Fee for Service (FFS) patients as well as any other payers identified by the organization in a manner consistent with all pertinent coding and compliance regulations.
- Case review prioritization is based on the prioritization by the organization and may also include review of records for accuracy of documentation related to APR-DRG classification and Quality Data elements ( Patient Safety Indicators, Readmissions, etc.).
Requirements :
- CA RN Licensure
- At least years of CDI experience in a complex acute care setting.
- Unit Manager is looking for CDI NURSES! - CDI experience as an RN is a MUST
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