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The Clinical Documentation Specialist reviews medical records to ensure accurate representation of illness severity and facilitates documentation improvements. They collaborate with physicians and clinical staff to clarify documentation and participate in task force meetings.
Compensation range:
$51.76 - $69.88Your rate of pay will be based on applicable experience
Shift: DaysEnloe Health is a Level II Trauma Center located in beautiful Northern California. We offer a full array of medical services, and our mission is to elevate the health of the communities we serve. As a Planetree organization, we place high value on hiring the right team to care for our patients and their families—care that is steeped in compassion, human connection, and mutual support. If you feel called to make a meaningful impact through empathetic, person-centered care, and thrive in a culture that values collaboration and purpose, we welcome you to join our team.
POSITION SUMMARY:
The Clinical Documentation Specialist (CDS) is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness. This involves the extensive record review, interaction with physicians, clinical staff, and HIM professionals. Utilizing advanced clinical knowledge, the CDS role requires the ability to review the medical record accurately and timely, recognize opportunities for documentation improvements, formulate clinically credible documentation clarifications, follow-up timely on all cases, especially those requiring clinical documentation clarifications, and communicate effectively and appropriately with the physicians. The CDS participates in the Task Force Meetings and collaborates on developing education for medical staff.
EDUCATION / TRAINING / EXPERIENCE:
Minimum:
Desired:
LICENSES / CERTIFICATIONS:
Minimum:
SKILLS / KNOWLEDGE / ABILITIES:
Must have excellent verbal and written communication skills and advanced critical thinking skills and be able to maintain strong, positive working relationships with medical staff. Understands and supports the CDI documentation strategies and concepts. Demonstrates advanced clinical expertise including understanding of nursing anatomy/pathophysiology, disease processes, pharmacology, advanced critical thinking, deductive reasoning and problem solving skills. Demonstrates organizational, analytical and interpersonal skills. Requires strict HIPPA compliance. Demonstrates ability to interact with a wide variety of individuals and handle multiple priorities. Proficiency in computer use, including database programs, presentation programs, word processing and internet search. Ability to work independently, be self-motivated, and adaptable to changes in work environment. Must be able to interact professionally with various colleagues and foster a team environment. Must be able to perform the essential functions of the position.
Enloe offers a comprehensive and competitive benefits package to all eligible employees, including, but not limited to:
Please visit the employee benefits page at http://www.enloe.org/benefits to get more in-depth benefits and coverage information or email recruiter@enloe.org to receive a full summary of benefits.
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