Clinical Documentation Specialist II

Overview

Embark on a rewarding career with Doctors Medical Center of Modesto hospital. If you are a compassionate healthcare professional eager to contribute to patient care, this is your opportunity where your skills make a difference every day. Join us in delivering exceptional healthcare with a personal touch.

At Doctors Medical Center Of Modesto, we understand that our greatest asset is our dedicated team of professionals. That’s why we offer more than a job – we provide a comprehensive benefit package that prioritizes your health, professional development, and work‑life balance. The available plans and programs include:

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

Note
:
Eligibility for benefits may vary by location and is determined by employment status.

Shift: Days
Job Type: Per Diem

Reporting to the Manager, CDI (Corporate), the Clinical Documentation Specialist (CDS) will be responsible for facilitating concurrent documentation of the medical record to achieve accurate inpatient coding and legitimate DRG assignment. The initial focus will be on the Medicare population.

• On a daily basis, initiate and perform concurrent documentation review of selected inpatient records to clarify conditions, diagnoses, and procedures where inadequate or conflicting documentation is suspected.
• Communicate with the physician or medical staff department to facilitate complete and accurate documentation of the inpatient record.
• Serve as a resource for physicians to help link ICD-9-CM coding guidelines and medical terminology to improve accuracy of final code assignment.
• Collaborate with the health information department in concurrently reviewing the inpatient medical record to assure correct provisional and final DRG assignment.
• Identify opportunities for intradepartmental and interdepartmental operational improvements.
• Monitor and evaluate the effectiveness of concurrent coding outcomes at designated intervals using the Tenet Enterprise Reporting portal.
• Report concurrent coding outcomes to hospital departments and committees at designated intervals.
• Maintain accurate records of review activities to comply with departmental and regulatory agency guidelines.

Minimum Education:

(not specified)

• 3 years clinical experience in an acute care setting OR 3 years CDI experience
• 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
• Working knowledge of Medicare reimbursement system and coding structures desired, not required
• 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
• Excellent written and verbal communication skills
• Excellent critical thinking skills
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.

• Current California Registered Nurse License or CDI/CCS Certification

• Ability to stand and walk for periods of time; lift/position up to 25 lbs; push/pull up to 25 lbs of force. Reaching, sitting, twisting, bending, manual dexterity and mobility. Touch, auditory and visual perception and acuity. Adequate vocal pitch and volume of voice. Ability to move quickly.

• Sufficient perceptive acuity (vision and hearing) to perform all the related…