Clinical Documentation Specialist

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.

• Facilitating concurrent documentation of the medical record to achieve accurate inpatient coding and legitimate DRG assignment
• 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

• 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

• 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

Doctors Medical Center of Modesto Hospital is committed to providing exceptional patient care in a supportive and collaborative environment.