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Clinical Documentation Specialist

Trios Health

This is a Contract position in Las Vegas, NV posted August 2, 2022.

The Clinical Documentation Specialist (CDS) reviews patient records concurrently and provides ongoing physician education to assure the quality and completeness of clinical documentation.

The CDS works collaboratively with physicians to assure that documentation accurately reflects a patient’s severity of illness, risk of mortality and complexity of care.

The CDS assures that the clinical documentation for clinical conditions and/or procedures supports the appropriate DRG assignment.

The CDS educates members of the patient support team (providers, allied staff, nurses and case management) regarding documentation guidelines and upcoming changes that will be required in documentation to support ICD-10 coding.

The CDS provides ongoing reports to demonstrate the impact of the CDP.

The CDS works closely with the CD physician champion.

The CDS works with physicians to assure that they respond to coding queries in a timely manner.

The CDS actively participates on the Clinical Documentation Committee, Revenue Cycle Committee, and the RAC Committee.

The CDS participates in and drives HIM Revenue Cycle improvement efforts.

– Associates Degree or equivalent from two-year college
– required.

Bachelor’s Degree
– PreferredExperience
– Minimum4
– years in Health Information Management Experience requiredLicensure/Certifications
– Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP)
– required within 24 months