Job Description

Clinical Documentation Specialist - Clinical

SUMMARY: Conducts concurrent reviews of clinical documentation in the medical record to obtain accurate and complete provider documentation for all conditions and procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. Responsible for ICD-10 diagnoses and procedure coding of medical record for an initial, working and final DRG. Collaborates extensively with physicians, nursing staff, other patient caregivers, and medical records coding staff to improve quality and completeness of documentation of care provided and coded. . Reviews claim denials pertaining to documentation and clinical validation issues for education opportunities and timely filing of appeals. Provides follow-up education to medical staff regarding high-quality clinical documentation guidelines and practices.



  • Minimum three (3) years clinical experience in an acute care setting, preferably in pediatrics or case management OR minimum two (2) years experience in a clinical documentation program and one (1) year clinical experience in an acute care setting, preferably in pediatrics or case management
  • Knowledge of APR-DRG assignment, and clinical conditions or procedures
  • Demonstrate knowledge of complete and accurate clinical documentation as well as coding and billing practices in all healthcare settings and for all healthcare disciplines.
  • Knowledge of coding conventions, rules, and guidelines.
  • Knowledge of coding and operational implications of ICD-10.
  • Knowledge of medical terminology, disease processes, and pathophysiology.
  • Strong organization, prioritization, critical thinking, and problem-solving skills.
  • Excellent communication, interpersonal skills, analytical and critical thinking skills.
  • Strong understanding of the requirements for clinical coding and billing according to the rules of Medicare, Medicaid, and commercial health plans along with knowledge of Interqual and medical necessity criteria.


  • Bachelor’s degree in Nursing, Medical or Health Information Technology/Management or graduate or a Physician Assistant (PA) program
  • Clinical Documentation Improvement Practitioner (CDIP) OR Certified Clinical Documentation Specialist (CCDS) is required
  • Certified Coding Specialist (CCS) is required


  • Full-time, 80 hours per pay period, M-F, 8-5


  • $43.50 - $66.60


  • Madera, CA

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