Clinical Documentation Specialist

4 days ago


San Francisco, California, United States CPMC Van Ness Campus Full time
Job Summary

We are seeking a highly skilled Clinical Documentation Specialist to join our team at CPMC Van Ness Campus. As a Clinical Documentation Specialist, you will play a critical role in ensuring the accuracy and completeness of patient medical records.

Key Responsibilities
  • Facilitate Complete and Specific Clinical Documentation: Utilize clinical experience and knowledge to ensure that patient medical records are complete and specific, meeting the highest standards of quality and accuracy.
  • Conduct Extensive Record Review: Review patient medical records to identify areas for improvement and ensure compliance with regulatory requirements.
  • Collaborate with Healthcare Professionals: Work closely with physicians, allied health professionals, health information management professionals, and nursing staff to ensure that patient medical records are accurate and complete.
  • Implement Concurrent Review Process: Utilize a concurrent review process to promote optimized severity of illness and quality in the medical record.
  • Classify MS-DRG and APR-DRG: Classify patient cases using MS-DRG and APR-DRG classification systems, and ensure that quality data elements are accurately captured.
Requirements
  • CA RN Licensure: Possess a current and active California RN license.
  • CDI Experience: Have at least 2 years of experience in Clinical Documentation Improvement (CDI) in a complex acute care setting.
Work Schedule

Monday through Friday, 5 days a week, with start times from 7:00 AM to 8:30 AM.



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