Clinical Documentation Specialist (CDS)

Prime Healthcare; Inglewood (CA); Hybrid; USD 70,000 - 100,000; Full time

Job summary

Centinela Hospital Medical Center, part of Prime Healthcare, seeks a Clinical Documentation Specialist to review inpatient records for accuracy of care documentation and reimbursement. The CDS will work closely with medical staff to optimize documentation, admission criteria, and chart completeness in a busy acute-care setting.

The ideal candidate has acute-care experience and strong communication, critical thinking, and teamwork skills to improve clinical documentation and support patient care

Qualifications

• Medical graduate, PA or nursing graduate with acute care exposure.
• Clinical documentation systems knowledge and patient care coding basics.
• Strong written and spoken communication, analytical thinking.
• Ability to work independently in fast-paced hospital settings.
• Familiarity with age-specific care needs and disease processes.
• Experience with inpatient admission criteria and documentation.

Responsibilities

• Perform concurrent and retrospective reviews of inpatient records.
• Ensure clinical documentation reflects quality of care and reimbursement.
• Collaborate with medical staff to improve documentation of patient care.
• Support admission criteria reviews and ongoing chart documentation.

Skills

Communication skills

Verbal communication

Critical thinking

Interpersonal skills

Independent work

Computer literacy

Assertive personality

Clinical knowledge

Education

Medical graduate / PA / Nursing graduate

ECFMG certificate or RN license

BCLS (AHA) certificate

ACLS certificate

Job description

Overview

At Centinela Hospital Medical Center, our dedicated team of professionals are committed to our core values of quality, compassion, and community. As a member of Prime Healthcare, a Top-15 hospital system in the United States, Centinela Hospital Medical Center is actively seeking new members to join its award-winning team!

Centinela Hospital Medical Center has been serving the communities of Inglewood and the wider Los Angeles area for 100 years. An award-winning facility, ranking in the top 5% nationally for quality and patient safety, Centinela Hospital is a 362-bed acute-care hospital with a 24-hour STEMI certified emergency department and primary stroke center, orthopedic care, advanced cardiac services, critical care services, inpatient and outpatient rehab programs, and more. Centinela has earned hundreds of national awards and recognitions, including "100 Top Hospital" recognition from Fortune/Merative and straight 'A's (2018-2024) for hospital safety from The Leapfrog Group.For more information, visit www.centinelamed.com.

Responsibilities

The Clinical Documentation Specialist (CDS) is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records. These reviews are to evaluate whether the clinical documentation is reflective of the quality-of-care outcomes and reimbursement compliance for acute care services provided. The CDS works 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. He/She will perform other duties as assigned or required.

Qualifications

EDUCATION, EXPERIENCE, TRAINING

Required Qualifications:

• Medical Graduate, PA or Nursing Graduate
• Minimum of one (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 the elements of disease processes and related procedures
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Excellent written, and verbal communication skills and critical thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment.
• Computer literacy and familiarity with the operation of basic office equipment
• Assertive personality traits to facilitate ongoing physician communication.

Preferred Qualifications:

• ECFMG Certificate or RN license
• Prior Case Management Experience
• Working knowledge of the Medicare reimbursement system and coding structures
• Current BCLS (AHA) certificate upon hire and maintain current.
• ACLS Certificate

Pay Transparency

Centinela Hospital Medical Center offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $XX.00 to $XX.00. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.

Employment Status

Full Time

Shift

Days

Equal Employment Opportunity

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf

Privacy Notice

Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf