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Clinical Documentation Specialist

HealthTECH Resources, Inc.
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Post Date: Jul 09, 2018
Job Type: Contract
Start Date: ASAP
Compensation: DOE
Location: US - California - Los Angeles
Reference: - n/a -
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HealthTECH Resources has urgent need for a Clinical Documentation Specialist for a one month on-site contract position at a premier healthcare client in CA starting ASAP. Interested candidates should have 6 - 10 years of clinical experience in an acute care setting with ICU background.

Main duties of the CDM Revenue Cycle Analyst

  • Provides concurrent review of the clinical documentation in the medical record; reviews the medical record with a clinical lens and identifies any missing or understated diagnoses. The key responsibility is to review the chart for information not currently in the chart but supported by clinical clues.
  • Queries the medical staff when necessary by written and verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality.
  • Performs a thorough chart review to determine the most appropriate principle diagnosis of the patient.
  • Performs a thorough chart review to identify co-morbidities/complications and documents these appropriately within the concurrent CDS worksheet.
  • Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality ratings/profiling purposes.
  • Coordinates with coding/HIM/UR and other departments to ensure the coded record reflects the the acuity of patients and level of provider care.

What qualifications will the ideal candidate have?

  • Bachelor’s Degree or higher in Nursing
  • Current RN License and Certification in Case Management
  • 6 - 10 years of clinical experience in an acute care setting with ICU background
  • Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues.
  • Assertive personality traits to facilitate ongoing physician communication. Ability to work independently in a time-oriented environment.

Why work here?

  • ?This is a hospital and health system you will love working for, in a stunningly beautiful city on the West Coast. Living here might make you want to retire here.
  • You will work at a not-for-profit health system that has been providing advanced medical care for patients for over 100 years and their nationally recognized services provide families with the patient-centered care they deserve.
  • Through partnership with physicians and their communities, this hospital is recognized as a state leader in quality care, safety, patient experience, transparency, cost effectiveness, and community health.

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