Clinical Documentation Specialist

2 weeks ago


Redlands, United States Redlands Community Hospital - MEDICAL RECORDSHIM Full time

**Position Details**:

- Salary: 44.38 - 64.35 Hourly
- Shift: Days, 8-hour shifts
- Status: Full-Time

Reporting to the Director of Health Information Management, this position is responsible for facilitating concurrent documentation of the medical record to achieve accurate inpatient coding and legitimate DRG assignment. Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. Includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. This position plays a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.

**QUALIFICATIONS**:
1. 3-5 years clinical experience in an acute care setting preferred. Case Management and/or coding experience a plus.

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

3. CDS I requires current valid California LVN license.



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