Clinical Documentation Specialist

Job Summary:

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 or diagnosis specific review criteria for CORE measure decision trees within the set time frames. May also review inpatient and outpatient records as part of the hospital wide medical record review program for the Joint Commission. Captures and maintains the related review data in designated computer systems or databases. 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.

Educational Requirements:

High School Diploma/GED Required.
Bachelor's Degree in Nursing or Health Information Management Preferred
Foreign Medical Degree, MBBS, MBBCH will be considered.

Licenses:

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;
Clinical Documentation Improvement Professional - or Certified Clinical Documentation Specialist Preferred

Experience:

Acute Care Experience - 3 Years Required
Utilization Review, Coding, or Case Management experience – Preferred

Physical Demands:

Sit at a desk or table with some walking, standing, bending, stooping, or carrying of light objects - Frequently
Perform continuous operation of a personal computer for four hours or more. - Constantly
Use hands and fingers to handle and manipulate objects and/or operate equipment. -Constantly
Bend, crouch, stoop, stretch, or crawl. Bend upper torso and reach up and out with hands and arms. – Rarely

Cedars-Sinai is a leader in providing high-quality healthcare encompassing primary care, specialized medicine and research. Since 1902, Cedars-Sinai has evolved to meet the needs of one of the most diverse regions in the nation, setting standards in quality and innovative patient care, research, teaching and community service. Today, Cedars- Sinai is known for its national leadership in transforming healthcare for the benefit of patients. Cedars-Sinai impacts the future of healthcare by developing new approaches to treatment and educating tomorrow's health professionals. Additionally, Cedars-Sinai demonstrates a commitment to the community through programs that improve the health of its most vulnerable residents.

Cedars-Sinai is one of the largest nonprofit academic medical centers in the U.S., with 886 licensed beds, 2,100 physicians, 2,800 nurses and thousands of other healthcare professionals and staff. Choose this if you want to work in a fast-paced environment that offers the highest level of care to people in the Los Angeles that need our care the most.

: HRC1472264

: Clinical Documentation Specialist

: CSRC CDI Services

: Cedars-Sinai Medical Center

: Patient Financial Services

: Revenue Integrity

: NONEXEMPT

: Day

: 8 hour

: $49.04 - $78.46

Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law. If you need a reasonable accommodation for any part of the employment process, please contact us by email at [email protected] and let us know the nature of your request and your contact information. Requests for accommodation will be considered on a case-by-case basis. Please note that only inquiries concerning a request for reasonable accommodation will be responded to from this email address.

Cedars-Sinai will consider for employment qualified applicants with criminal histories, in accordance with the Los Angeles Fair Chance Initiative for Hiring.

At Cedars-Sinai, we are dedicated to the safety, health and wellbeing of our patients and employees. This includes protecting our patients from communicable diseases, such as influenza (flu) and COVID-19. For this reason, we require that all new employees receive a flu vaccine based on the seasonal availability of flu vaccine (typically during September through April each year) as a condition of employment, and annually thereafter as a condition of continued employment, subject to medical exemption or religious accommodation. For the same reason, you may also be required to receive other vaccines such as COVID-19 as a condition of employment. Cedars-Sinai reserves the right to make modifications to its required list of vaccines as required by law and/or policy. Cedars-Sinai’s AA Policy Statement (PDF) (opens in new window)