Clinical Documentation Specialist

Doctors Medical Center of Modesto Hospital is committed to providing exceptional patient care in a supportive and collaborative environment. As a member of our team, you will have the opportunity to work with advanced technology and be part of a healthcare community dedicated to making a positive impact on the lives of our patients.

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: Day

Job type: Full Time

Hours:

Position Summary

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.

Minimum Experience/Skills:

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.

License/Certificates/Credentials:

Current California Registered Nurse License or CDI/CCS Certification

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Minimum Experience/Skills:

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.

License/Certificates/Credentials:

Current California Registered Nurse License or CDI/CCS Certification