Acute Care Clinical Documentation Specialist

Centinela Hospital Medical Center; Inglewood (CA); On-site; USD 85,000 - 110,000; Full time

Job summary

Centinela Hospital Medical Center is seeking a Clinical Documentation Specialist (CDS) to perform concurrent and retrospective reviews of inpatient records, ensuring documentation reflects care quality and reimbursement. You will work closely with physicians and nursing staff to improve clinical documentation and ensure compliance.

Ideal candidates have 1+ year in acute care, strong communication, and solid knowledge of admission criteria.

Qualifications

• Required: Medical Graduate, PA or Nursing Graduate.
• Minimum of 1+ year’s clinical experience in an acute care setting.
• Knowledge of care delivery documentation systems and related medical record documents.
• Knowledge of age-specific needs and disease process elements.
• Strong clinical knowledge of pathology/physiology.
• Excellent written and verbal communication and critical thinking.
• Excellent interpersonal skills for physician, nurse, and management relationships.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment.
• Computer literacy and basic office equipment operation.
• Assertive personality to facilitate physician communication.

Responsibilities

• Conduct concurrent and retrospective reviews of inpatient medical records.
• Evaluate whether documentation reflects care quality and reimbursement.
• Collaborate with medical staff to facilitate clinical documentation.
• Document inpatient admission criteria and extended-stay reviews.
• Perform other duties as assigned or required.

Skills

Medical Grad

Acute care exp

Documentation systems

Age-specific care

Clinical knowledge

Communication skills

Interpersonal skills

Admission criteria

Independent work

Computer literacy

Assertive communication

Education

Medical/PA/Nursing graduate

ECFMG Certificate

RN license

ACLS Certificate

BCLS Certificate

Case management experience

Job description

Centinela Hospital Medical Center is seeking a Clinical Documentation Specialist (CDS) to perform concurrent and retrospective reviews of inpatient records, ensuring documentation reflects care quality and reimbursement. You will work closely with physicians and nursing staff to improve clinical documentation and ensure compliance.

Ideal candidates have 1+ year in acute care, strong communication, and solid knowledge of admission criteria.