Clinical Documentation Specialist (CDS)
|Minimum Requirements:||Registered Nurse or Foreign Medical Doctor desired, will consider Nurse Practitioner or Physician Assistant
Minimum of 5 years in clinical practice
Critical care or strong medical / surgical background
The CDS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness. This involves extensive record review, interaction with physicians, HIM professionals, and nursing staff. Active participation in team meetings and education of staff in the CDMP® process is a key role.
The Primary Function of the CDS
Review inpatient medical records for identified payer populations on admission and throughout hospitalization.
Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.
Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA) and quality core measures, patient safety indicators (PSI)
Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses and ancillary staff.
Work collaboratively with the coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care.
Develop and implement plans for education of physician, nursing and ancillary staff on documentation improvement.
Are you a returning applicant?
|Back to Search Results
Mount Sinai Medical Center