• Clinical Documentation Specialist

    Pomona Valley Hospital Medical Center (Pomona, CA)


    FULLY REMOTE POSITION

    Job Summary: The Clinical Documentation Integrity Specialist (CDIS) is responsible for facilitating the improvement in the quality and completeness of medical record documentation. The CDIS obtains appropriate clinical documentation through extensive interaction with physicians, multi-disciplinary team, and Health Information Management Associates to ensure that the medical record accurately reflects the patient’s clinical condition and treatment rendered resulting in accurate reimbursement and outcomes reporting. Maintains current knowledge and understanding of ICD-10 CM & PCS coding, DRG systems and AHIMA Coding Clinic & Coding guidelines. May perform other duties as assigned.

     

    Required qualifications: Current unrestricted California RN license. Graduate of accredited School of Nursing with Associates degree. Three years acute hospital/clinical experience and minimum one year of Clinical Documentation Specialist experience. Candidate must have technical knowledge of ICD-10, MS-DRG and APR-DRG assignment and prospective payment methodologies. In addition, strong knowledge of clinical documentation guidelines required. Must be detail oriented, have the ability to work independently, exercise good judgment and be resourceful. Position requires strong interpersonal skills to work with key stakeholders, physicians and/or clients and staff. Position requires strong organizational and time management skills and ability to teach and present educational topics. Data entry and typing required.

     

    Preferred Qualifications: Bachelor's degree. CCDS, CDIP, or CCS. Adult inpatient, NICU, OB and Trauma experience is a plus both from clinical and CDI perspective.

     

    Salary range: $64.75 - $95.72