Clinical Documentation Sp

Pioneers Memorial Healthcare District; Brawley (CA); On-site; USD 73,000 - 86,000; Full time

Job summary

Pioneers Memorial Healthcare District in Brawley, CA seeks a Clinical Documentation Specialist (Full Time) to review medical records and facilitate accurate severity of illness representations. You will collaborate with physicians, HIM professionals, and nursing staff to ensure CDMP alignment and proper documentation practices.

Responsibilities include learning CDMP processes, precise data input into CDMP Trak, resolving discrepancies, and participating in cross‑functional meetings to improve

Qualifications

• RN license required and CPR certification.
• Experience with hospital records and CDMP preferred.
• Strong written and verbal communication with clinical staff.

Responsibilities

• Review medical records to accurately represent severity of illness.
• Interact with physicians, HIM professionals, and nursing staff.
• Input data into CDMP Trak and support CDMP documentation strategies.
• Communicate discrepancies and resolve issues with care teams.
• Participate in Task Force Meetings and staff education.

Skills

Organizational skills

Analytical thinking

Writing ability

Interpersonal skills

Communication with physicians

Critical thinking

Education

RN license

BSN preferred

Tools

CDMP Trak

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Clinical Documentation Sp

Full Time CLERICAL Brawley, CA, US

3 days ago Requisition ID: 1798

Salary Range: $35.42 To $41.12 Annually

SUMMARY:

The CDS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness. This involves extensive record review, interaction with physicians, Health Information Management professionals, and nursing staff. Active participation in team meetings and education of staff in the CDMP® process is a key role .

ESSENTIAL FUNCTIONS:

Job functions reflect the following objectives:

• Ability to learn/develop the skills necessary to perform CDMP®
• Accurate and timely record review
• Formulate clinically credible documentation clarifications
• Effective and appropriate communication with physicians
• Timely follow up on all cases especially those with clinical documentation clarifications
• Participate in Task Force Meetings
• Communicates with HIM staff and resolves discrepancies

Accurate input of data into CDMP Trak®

OTHER RESPONSIBILITIES:

• Performs other duties as assigned .

KNOWLEDGE, SKILLS, ABILITIES, AND EXPERIENCE REQUIRED:

• Organizational, analytical, writing and interpersonal skills
• Dependable, self directed and pleasant
• Critical thinking, problem solving and deductive reasoning skills
• Recent hospital experience preferably ICU, CCU, or strong Med/Surg.
• Knowledge of Pathophysiology and Disease Process
• Basic Computer skills – familiarity with Windows based software programs
• Knowledge of Medicare Part A
• Familiar with Medicare Part B
• General understanding of hospital based Quality initiatives (training provided)
• Knowledge of regulatory environment
• Understand and support CDMP® documentation strategies (upon completion of training)
• Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments

LICENSES AND CERTIFICATIONS:

• Graduation from a program of nursing, BSN, preferred.
  • Current California Registered Nurse license required
  • Current American Heart Association CPR required.

AGE OF POPULATION SERVED :

Newborn Infant/Pediatric Adolescent Adult Geriatric All No Patient Care