Reporting to the Chief Information Office, the Clinical Documentation Specialist (CDS) will be responsible for facilitating concurrent documentation of the medical record to achieve accurate inpatient coding and legitimate DRG assignment.The initial focus will be on the Medicare population.
Bachelors of Science in Nursing or Bachelors of Medicine (American or International, or Bachelors of Science in HIM (with inpatient coding background) 2+ years CDS experience preferred.
Demonstrate knowledge of clinical or inpatient coding experience in an acute care setting
Familiarity with CDI concepts desired.
Knowledge of care delivery documentation systems and related medical record documents.
Knowledge of age specific needs and the elements of disease processes and related procedures.
Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
Excellent written and verbal communication skills.
Excellent critical thinking skills, interpersonal skills to build effective partnering relationships with physicians, nurse staff, hospital management staff, and health information systems coding staff.
Ability to work independently in a time sensitive environment to meet productivity standards.
Computer literacy and familiarity with the operation of basic office equipment.
Assertive personality traits to facilitate ongoing physician communication.
Ability to stand and walk for periods of time is required in the performance of job responsibilities.
Job: Information Systems
Primary Location: Modesto, California
Facility: Doctors Medical Center of Modesto
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâs or employeeâs race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.