Clinical Documentation Specialist - San Francisco Job at IDR, San Francisco, CA

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  • IDR
  • San Francisco, CA

Job Description

IDR is seeking a dedicated and experienced Clinical Documentation Specialist to join one of our top clients in San Francisco, CA . This role is pivotal in ensuring accurate and comprehensive clinical documentation in medical records. If you have a strong clinical background and are looking for an opportunity to join a large, growing organization with a team-oriented culture, we encourage you to apply today!

Position Overview/Responsibilities for the Clinical Documentation Specialist:

  • Conducting thorough record reviews and collaborating with physicians, allied health professionals, health information management teams, and nursing staff

  • Conducting concurrent reviews to enhance documentation accuracy and optimize severity of illness representation

  • Ensuring compliance with MS-DRG classification per Centers for Medicare and Medicaid Services (CMS) guidelines

  • Reviewing documentation for Medicare Fee-for-Service (FFS) patients and other payers identified by the organization

  • Prioritizing case reviews based on organizational guidelines, including APR-DRG classification and quality data elements (e.g., Patient Safety Indicators, Readmissions)

Required Skills for Clinical Documentation Specialist:

  • Minimum of 2 years of Clinical Documentation Improvement (CDI) experience in a complex acute care setting

  • Familiarity with MS-DRG and APR-DRG classification systems

  • Knowledge of Centers for Medicare and Medicaid Services (CMS) compliance regulations

  • Strong clinical expertise and ability to work collaboratively with a diverse team

What’s in it for you?

  • Competitive compensation package

  • Full Benefits; Medical, Vision, Dental, and more!

  • Opportunity to get in with an industry-leading organization

  • Close-knit and team-oriented culture

Why IDR?

  • 25+ Years of Proven Industry Experience in 4 major markets

  • Employee Stock Ownership Program

  • Medical, Dental, Vision, and Life Insurance

  • ClearlyRated's Best of Staffing® Client and Talent Award winner 11 years in a row

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. IDR is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, we invite employees to voluntarily self-identify their race or ethnicity, gender, and veteran status (if applicable). Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. You may access this form here.

Job Tags

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