Job Description

The CDS is responsible for the concurrent review of medical records to assure appropriateness of care, accuracy of documentation, validation of severity of illness and quality of services provided. The CDS will audit charts for appropriateness of admission, continued stay, compliance to hospital metrics and appropriate documentation based on diagnosis and severity of illness. The Quality CDS will interact with physicians, nurses and other professionals regarding documentation and actively participate in team meetings to improve physician and clinical staff chart documentation. Patient charts not meeting approved guidelines will be selected for peer review and follow-up.

PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Downey Hospital, PIH Health Good Samaritan Hospital, PIH Health Whittier Hospital, 37 outpatient medical office buildings, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, digestive health, orthopedics, women’s health, urgent care and emergency services. The organization is nationally recognized for excellence in patient care and patient experience, and the College of Healthcare Information Management Executives (CHIME) has identified PIH Health as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. For more information, visit PIHHealth.org or follow us on Facebook , Twitter , or Instagram .

Required Skills

• Organizational, analytical, writing and interpersonal skills
•   Dependable and self-directed
•   Critical thinking, problem solving and deductive reasoning skills
•   Basic computer skills, familiarity with Windows based software programs
•   Knowledge of Medicare Part A
•   Familiar with Medicare Part B
•   Knowledge of regulatory environment
•   Understand and support CDMP® documentation strategies
•   Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments

Required Experience

Required:

• Graduation from accredited School in Nursing with BSN
• Current licensure as a RN in the State of California; or International Physician Medical graduate.
• Previous Clinical Documentation Specialist in an acute care setting, minimum of 2 years
• A minimum of 3-5 years’ experience in Critical Care or Emergency Department nursing or physician clinical experience.
• LA City Fire Card within6 months of employment (PHGSH only)

Preferred:

• RN Degree in Nursing, a Bachelor’s or Master’s Degree
• Certified Coding Specialist Certification (CCS)

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