JOB SUMMARY:   The Clinical Documentation Specialist (CDS) is responsible conducting clinically based clinical

Concurrent and retrospective reviews of inpatient medical records.  This review is to evaluate that the clinical documentation is 

reflective of quality of care outcomes and reimbursement compliance for acute care services provided.  The CDS will work closely with the medical staff to facilitate appropriate clinical documentation of patient care.  Other responsibilities include

Conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings.

EDUCATION, EXPERIENCE, TRAINING

1. Medical Graduate, PA or RN with current valid license and relevant education..
2. CCS Certification required.
3. Minimum of 3+ years clinical experience in an acute care setting.
4. Prior Case Management experience is desirable.
5. Knowledge of care delivery documentation systems and related medical record documents. 
6. Knowledge of age-specific needs and the elements of disease processes and related procedures..  
7. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
8. Excellent written and verbal communication skills.  Excellent critical thinking skills.
9. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.
10. Working knowledge of inpatient admission criteria.
11. Ability to work independently in a time-oriented environment.
12. Computer literacy and familiarity with the operation of basic office equipment.
13. Assertive personality traits to facilitate ongoing physician communication.
14. Working knowledge of Medicare reimbursement system and coding structures preferred.
15. Current BCLS (AHA) certificate upon hire and maintain current; preferred.
16. ACLS preferred.