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Clinical Documentation SpecialistCompany ProMedica
Update 5 Day ago
ProMedica is a locally-owned, nonprofit health system
providing quality health care services to 27 counties in
northwest Ohio and southeast Michigan. We’re a network
of hospitals, physicians, health care professionals,
researchers, and specialty clinics and facilities. We
offer a full range of diagnostic, medical, and surgical
specialties in areas such as emergency medicine and
trauma, heart and vascular, oncology, orthopedics,
neurology, women’s services, and children’s services.
The Clinical Documentation Specialist (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, clinical staff and HIM coding professionals.
Active participation in team meetings and education of
staff in the clinical documentation improvement program
are key functions of this role.
- Performs daily Clinical Documentation Improvement
review, identification of opportunities for
documentation improvement, formulation of
clarifications, as well as compliant and effective
communication with physicians and other clinical
staff to obtain needed documentation.
- Demonstrates knowledge of DRG methodologies and
improvement and is able to effectively apply those
guidelines and identify opportunities.
- Formulates clinically credible and compliant
clarifications and compliance with physicians,
clinical staff and HIM coding professionals as
- Understands and communicates differences between
they impact DRG assignment and other data reporting
- Develops and delivers education to physician and
- Collaborates effectively with team to ensure the
effective communication and conflict management
- Effectively manages multiple priorities and
- Performs other related duties as assigned.
- RN with active license required, or RHIA/RHIT
- CCS or CDIP credentials preferred.
- Experience with acute care inpatient coding or
- Strong interpersonal skills and communication skills
- Experience working with Electronic Medical Record
- Ability to input data into computer required.
- Must be able to move about hospital and between
- Must maintain continuous education and enhance
Qualified applicants will receive consideration for
employment without regard to race, color, national
origin, ancestry, religion, sex, pregnancy, sexual
orientation, gender identity or gender expression, age,
disability, military or veteran status, height, weight,
familial or marital status, or genetics.
Equal Opportunity Employer/Drug-Free Workplace