CDS - Medical Records

Overview

Join an award-winning team of dedicated professionals committed to our core values of quality, compassion and community! Mission Regional Medical Center, a member of Prime Healthcare, offers incredible opportunities to expand your horizons and be part of a community dedicated to making a difference.

Mission Regional Medical Center is a 297-bed, non-profit hospital that provides inpatient and outpatient hospital services to the people of the Rio Grande Valley. Rated one of the top hospitals in the country for clinical excellence in many services including maternity and orthopedic care, Mission Regional Medical Center has been offering quality healthcare, close to home, for over 60 years. For more information visit .

Responsibilities

The Clinical Documentation Specialist (CDS) is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records. These reviews are to evaluate whether the clinical documentation is reflective of the quality-of-care outcomes and reimbursement compliance for acute care services provided. The CDS works closely with the medical staff to facilitate appropriate clinical documentation of patient care. Other responsibilities include conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings. The CDS will perform other duties as assigned or required.

Qualifications

EDUCATION, EXPERIENCE, TRAINING

1. Medical Graduate, PA or Nursing Graduate required

2. Minimum of three one (1+) years clinical experience in an acute care setting

3. Knowledge of care delivery documentation systems and related medical record documents

4. Knowledge of age-specific needs and the elements of disease processes and related procedures

5. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.

6. Excellent written, and verbal communication skills and critical thinking skills.

7. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.

8. Working knowledge of inpatient admission criteria.

9. Ability to work independently in a time-oriented environment.

10. Computer literacy and familiarity with the operation of basic office equipment.

11. Assertive personality traits to facilitate ongoing physician communication.

12. ECFMG Certificate or RN license preferred.

13. Prior Case Management Experience preferred.

14. Working knowledge of the Medicare reimbursement system and coding structures preferred.

15. Current BCLS (AHA) certificate upon hire and maintain current preferred.

16. ACLS Certificate preferred.

Employment Status

Full Time

Shift

Days

Equal Employment Opportunity

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: