Registered Nurse – Clinical Documentation Specialist - Days

Location: Turlock, CA
Date Posted: 10-20-2016
Job Title:   Registered Nurse – Clinical Documentation Specialist - Days
Location:   Turlock, CA.
Duration:   Full time
Salary:      Negotiable
The Clinical Documentation Specialist (CDS) reviews medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physicians’ clinical documentation. This involves extensive record review and interaction with physicians, Medical Records coders, case managers, and nursing staff. The CDS indirectly assures case mix index, Diagnostic Resource Group (DRG) assignment and accuracy of the physician profile data. This will be accomplished by doing concurrent review of the medical records along with query of the medical staff and other caregivers as necessary. This review may be accomplished via documentation prompters and/or verbal communication with the physician to obtain accurate and complete documentation which appropriately supports the severity of patient illness. Performs other duties as required.
·  Current California RN license, BSN preferred.
·  Acute care hospital experience a must.
·  Case Management, utilization review, and InterQual knowledge and experience a plus and preferred.
·  Detail oriented, assertive with excellent interpersonal and communication skills.
Candidate Details:
1+ to 2years experience
Minimum Education - Certification
Willingness to Travel - Occasionally
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