Clinical Documentation Specialist

Clinical Documentation Specialist 2780781

One of the most prestigious and well-known universities is seeking a Clinical Documentation Specialist. The successful candidate will be responsible and accountable for the day-to-day management and success of the continuous documentation improvement project to include all modalities, acting as a liaison with specific department staff, speaking, meeting, and educating physicians, residents, and mid-levels, and assisting with the development and implementation of clinical documentation improvement processes. The ideal candidate has five or more years of experience as a Clinical Documentation Specialist (CDS), some or all of which must be with an Academic Medical Center (AMC). The company offers a great work environment!

Clinical Documentation Specialist Pay and Benefits:

• Hourly pay: $70/hr
• Worksite: One of the most prestigious and well-known universities (Los Angeles, CA 90024 - Open to remote candidates in the United States)
• W2 Employment, Group Medical, Dental, Vision, Life, Retirement Savings Program
• 40 hours/week, 3 Month Assignment

Clinical Documentation Specialist Responsibilities:

• Gather and analyze information in order to provide for comprehensive medical record documentation that accurately reflects clinical treatment, decisions, and diagnosis for inpatients.
• Utilize clinical expertise and some coding knowledge to identify opportunities and ensure accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes, including quality measures.
• Supply support to the Medical Coders, Quality staff, and revenue cycle team in the complaint coding and processing of inpatient claims.

Clinical Documentation Specialist Qualifications:

• 5+ years of experience as a Clinical Documentation Specialist (CDS), some or all of which must be with an Academic Medical Center (AMC).
• Academic Medical Center (AMC) experience (preferably recent (last 12 months) or current).
• An RN or MD certification from a US School.
• Able to discuss medical diagnostic topics.
• Familiar with coding as it relates to documentation.
• Recent experience in an EPIC and 3M 360 Encompass (CAC) software environment.
• Consistent job history in CDI with contractor experience.
• Solid clinical/medical foundation (preferably someone with acute floor staff nursing experience).
• Extensive coding/regulatory/compliance knowledge.
• Strong technical and critical thinking ability.
• Ability to clearly and fluently articulate and discuss pathophysiology.
• Ability to effectively communicate to physicians/staff the necessity/appropriateness of clinical documentation.
• Working knowledge of laws, rules, and regulations regarding utilization review and discharge planning functions of government programs such as Medicare, Medi-Cal, and CCS.
• Immediate knowledge of computer word processing, database programs and ability to write reports and do graphical analysis.

Shift:

• Monday – Friday, 8:00 am to 5:00 pm.