What are the responsibilities and job description for the Clinical Documentation Specialist position at Redlands Community Hospital - MEDICAL RECORDS/HIM?
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.
4. CDS II requires current California RN license