The Clinical Documentation Specialist (CDS) facilitates improvement in the overall quality, completeness and accuracy of medical record coding and documentation. The (CDS) reviews inpatient medical records concurrently, while the patient is still in-house, facilitating appropriate physician documentation for any clinical conditions or procedures to support appropriate MS-DRG assignment, severity of illness, expected risk of mortality, core measures, and complexity of care of the patient. Obtains and promotes appropriate clinical documentation through interaction with the HIM department, physicians, nursing staff and other clinical providers of care. This includes review of all new admissions to the acute care facility, as well as, re-review until the patient is discharged. The CDS communicates with HIM, clinicians and physicians to ensure timely and accurate documentation and provides training and education as required.
Graduate from an accredited school of nursing or if a Coder-be a RHIT, RHIA or HIM Inpatient Coder with CCS.
Two years acute care nursing experience (e.g. medical-surgical, ICU, case management, etc) and coding and DRG experience or understanding/or a Health Information Management Professional with at least two years inpatient coding experience.
Licensed as a Registered Nurse in the State of Illinois required or if a Coder – be a RHIA, RHIT or HIM Inpatient Coder with CCS.
Health Information Management
IL-Marion (Southern Illinois)
Heartland Regional Medical Center
Forecasted paid hours per shift
Forecasted hours per pay week
Community Health Systems - 10 months ago