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Clinical Documentation Specialist - Medical Records - PRN
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- Description Summary: The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation.
- The CDS will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement are received for the level of services rendered to the patients.
- Updates DRG worksheet to reflect any changes to inpatient status/procedure/treatment and confers with the physician to finalize diagnosis.
- Requirements: Registered Health Information Management Administrator (RHIA) or Technician (RHIT) graduate of an approved college program for Health Information Management or graduate of the American Medical Record Associate’s Independent Study Course for Medical Record Technicians is required.
- College courses in medical terminology and anatomy and physiology preferred.
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