Clinical Documentation Specialist

Cedars-Sinai; Los Angeles (CA); Hybrid; USD 90,000 - 130,000; Full time

Job summary

Cedars-Sinai in Los Angeles seeks a Clinical Documentation Specialist to perform chart reviews and pre-charting for risk-adjusted patient populations. The role requires applying clinical knowledge to correlate diagnoses for PCPs during face-to-face visits, with diligent tracking of findings.

Responsibilities include leading or providing training to clinical and administrative teams on documentation requirements and developing educational materials as needed to support CMS and regulatory

Qualifications

• Experience with Medicare risk adjustment coding and documentation.
• Ability to train clinical and administrative staff on documentation requirements.
• Familiarity with risk adjustment analytics platforms is preferred.
• Proficiency in Microsoft Office (Excel/PowerPoint) for presentations.

Responsibilities

• Perform clinical chart reviews and pre-charting for risk-adjusted populations.
• Apply clinical knowledge to correlate diagnoses for PCP consideration during visits.
• Track and verify findings; ensure accurate documentation and coding.
• Lead or provide education to care and admin teams on documentation requirements.
• Develop educational materials as needed for training.

Skills

Medicare risk adjustment coding

Risk adjustment analytics

Training staff

Clinical documentation

Education

Bachelor's Degree in Nursing or Health Information Management

High School Diploma/GED

Tools

Microsoft Excel

PowerPoint

Job description

Job Description

This position is Hyrbid but will require travel throughout the Greater Los Angeles area on a regular basis.

The Clinical Documentation Specialist works independently and is responsible for performing clinical chart
reviews and pre-charting on risk adjustable patient populations. The Clinical Documentation Specialist
exercises critical thinking by applying clinical knowledge to correlate relevant diagnoses for the primary
care physician (PCP) to consider at the time of the face to face visit. The Clinical Documentation Specialist
will also be responsible for tracking and verifying all their findings.

Leads or provides education/training to clinical care and administrative support team members regarding
the clinical documentation requirements essential for risk adjustable diagnoses and their impact on
reimbursement and regulatory requirements set forth by CMS and other regulatory entities. Assists in
developing educational materials as needed.

Qualifications

Education

• High School Diploma/GED - minimum
• Bachelor's Degree Bachelor's Degree in Nursing or Health Information Management. - preferred

Experience

• 3 years Medicare risk adjustment coding & documentation required
• 2 years Experience providing training information to clinical and administrative
  staff preferred
• 3 years Experience using software such as Microsoft Office including Excel and
  PowerPoint to develop presentations preferred
• 1 year Exposure to risk adjustment analytics platform(s) to gain insights into
  risk adjustment performance and opportunities required

Licenses and Certifications

• Valid Clinical CA license preferred (PA, NP, LVN or RN)
• Registered Health Information Administrator preferred
• AHIMA or AAPC coding credential and/or registration (One or more of the following: CDIP, CDEO, CCS, CPC, CRC) required