Clinical Documentation Specialist (CDS) performs review of inpatient medical records to identify documentation opportunities to accurately represent the severity of illness, risk of mortality, length of stay, intensity of service and hospital quality metrics. Improves the overall quality and completeness of clinical documentation by working closely with providers and the application of coding guidelines, evidence-based knowledge, analysis, in-depth review, interpretation, identification of opportunities, communication, and consistent follow-up and evaluation of concurrent and retrospective (as required) medical record documentation.
Minimum Education:â¢Graduate of an accredited school of registered nursing and/or foreign medical graduate.Minimum Experience/Knowledge:â¢Minimum of 2 years of clinical documentation improvement experienceâ¢Minimum of 3 years of clinical experience in an acute care settingâ¢Demonstrates knowledge of ICD10-CM & PCS with respective coding guidelines & regulations for coding and reporting.â¢Proficient on Inpatient Prospective Payment System (IPPS) documentation requirements for proper APR and MS DRGs assignment.Required License/Certification:â¢Valid California Registered Nurse license and/or foreign medical graduate. (or valid state of residence Registered Nurse license for out-of-state employees [working remotely])â¢Certified Clinical Documentation Specialist (CCDS from ACDIS) or Certified Documentation Improvement Practitioner (CDIP from AHIMA) requiredâ¢Fire and Safety Certification. If no card upon hire, one must be obtained within 30 days of hire, and maintained by renewal before expiration date. (Not applicable to out-of-state employees [working remotely]).
USC is the leading private research university in Los Angeles—a global center for arts, technology and international business. With more than 47,500 students, we are located primarily in Los Angeles but also in various US and global satellite locations. As the largest private employer in Los Angeles, responsible for $8 billion annually in economic activity in the region, we offer the opportunity to work in a dynamic and diverse environment, in careers that span a broad spectrum of talents and skills across a variety of academic and professional schools and administrative units. As a USC employee and member of the Trojan Family—the faculty, staff, students, and alumni who make USC a great place to work—you will enjoy excellent benefits, including a variety of well-being programs designed to help individuals achieve work-life balance.