CDS (SMKIL) - PHMI Medical Records

Overview

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 54 hospitals and has more than 360 outpatient locations in 15 states providing more than 3.0million patient visits annually. It is one of the nation’s leading health systems with over 60,000 employees and physicians. Twenty-one of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team!

Responsibilities

The Clinical Documentation Specialist (CDS) is responsible conducting clinically based concurrent and retrospective reviews of inpatient medical records. This review is to evaluate that the clinical documentation is reflective of quality-of-care outcomes and reimbursement compliance for acute care services provided. The CDS will work 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.

Qualifications

EDUCATION, EXPERIENCE, TRAINING

Required qualifications:

1. Medical Graduate, PA or Nursing Graduate.
2. Minimum of one (1+) years clinical experience in an acute care setting in any capacity.
3. Knowledge of care delivery documentation systems and related medical record documents.
4. Knowledge of age-specific needs and the elements of disease processes and related procedures.
5. Strong broad-based clinical knowledge and understanding of pathology / physiology of disease processes.
6. Excellent written and verbal communication skills. Excellent critical thinking skills.
7. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff.

Preferred qualifications:

1. ECFMG Certificate or RN license preferred.
2. Working knowledge of inpatient admission criteria.
3. Ability to work independently in a time-oriented environment.
4. Computer literacy and familiarity with the operation of basic office equipment.
5. Assertive personality traits to facilitate ongoing physician communication.
6. Working knowledge of Medicare reimbursement system and coding structures.
7. Current BCLS (AHA) certificate upon hire and maintain current.
8. ACLS

Pay Transparency

Prime Healthcare 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 $28.00 to $43.40. 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.

The company is dedicated to empowering its staff with a comprehensive, competitive benefits package, allowing them the freedom to customize their benefits to fit their unique needs. Our abundant resources, programs, and voluntary options serve as a foundation for individual growth and well-being. Learn more here:

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: