Inpatient Clinical Documentation Specialist - Acute Care

Prime Healthcare; Evanston (IL); On-site; USD 58,000 - 90,000; Full time

Job summary

Prime Healthcare is seeking a Clinical Documentation Specialist (CDS) to perform concurrent and retrospective reviews of inpatient records, ensuring documentation accurately reflects quality of care and reimbursement standards. You will work closely with the medical staff to optimize clinical documentation and support admission criteria determinations.

The role requires a medical graduate or PA/nursing degree, 3+ years in acute care, and strong communication, analytical, and interpersonal

Qualifications

• Medical graduate (PA, Nursing, or MD) required.
• Minimum of 3+ years clinical acute care experience.
• Knowledge of care delivery documentation systems and medical records.
• Knowledge of age-specific needs and disease processes.
• Strong clinical knowledge of pathology/physiology.
• Excellent written and verbal communication and critical thinking.
• Excellent interpersonal skills for collaboration with physicians, nurses, and management.
• Ability to work independently in a time-oriented environment.
• ECFMG/RN license preferred; ACLS preferred; BCLS preferred.
• Inpatient admission criteria knowledge and Medicare reimbursement understanding preferred.

Responsibilities

• Conduct clinically based concurrent and retrospective reviews of inpatient medical records.
• Evaluate documentation for quality-of-care outcomes and reimbursement compliance for acute care services.
• Collaborate with medical staff to facilitate appropriate clinical documentation of patient care.
• Document findings for inpatient admission criteria and extended-stay reviews.
• Perform other duties as assigned or required.

Skills

Communication skills

Critical thinking

Interpersonal skills

Time management

Independent worker

Education

Medical graduate, PA or nursing graduate

ECFMG or RN license preferred

ACLS certificate preferred

BCLS certificate preferred

Job description

Prime Healthcare is seeking a Clinical Documentation Specialist (CDS) to perform concurrent and retrospective reviews of inpatient records, ensuring documentation accurately reflects quality of care and reimbursement standards. You will work closely with the medical staff to optimize clinical documentation and support admission criteria determinations.

The role requires a medical graduate or PA/nursing degree, 3+ years in acute care, and strong communication, analytical, and interpersonal