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CDS Clinical Documentation Specialist
Jobs
#410894
Full Time
Job Description
Job description
Overview
Join an award-winning team of dedicated professionals committed to our core values of quality, compassion and community! Shasta 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.
Shasta Regional Medical Center is a 226-bed acute care facility serving Northern California. The hospital offers a comprehensive range of services. Shasta Regional Medical Center is one of the nation’s 50 Top Cardiovascular Hospitals recognized by Watson Health and holds an ‘A’ Grade from Leapfrog Group, the nation's premier advocate of transparency in health care. The hospital is Joint Commission Certified for Stroke, Hip/Knee and Diabetes. They are a Five Star recipient for treatment of heart failure, respiratory failure and is named among the top 5% in the nation for patient safety. Shasta Regional Medical Center delivers patient-centered healthcare with compassion, dignity and respect for every patient and their family. For more information, visit www.shastaregional.com .
Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, ****** 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: https://www.eeoc.gov/sites/default/files/2026-10/EEOC_KnowYourRights_screen_reader_10_20.pdf
Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2026/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf
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. He/She will perform other duties as assigned or required.
Qualifications
EDUCATION, EXPERIENCE, TRAINING
Required Qualifications
• Medical Graduate, PA or Nursing Graduate
• Minimum of three (3) year’s clinical experience in an acute care setting
• Knowledge of care delivery documentation systems and related medical record documents
• Knowledge of age-specific needs and the elements of disease processes and related procedures
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes
• Excellent written, and verbal communication skills and critical thinking skills
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment
• Computer literacy and familiarity with the operation of basic office equipment
• Assertive personality traits to facilitate ongoing physician communication
Preferred Qualifications
• ECFMG Certificate or RN license
• Prior Case Management Experience
• Working knowledge of the Medicare reimbursement system and coding structures
• Current BCLS (AHA) certificate upon hire and maintain current
• ACLS Certificate
Shasta Regional Medical Center offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $28.00 to $43.40. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.
Overview
Join an award-winning team of dedicated professionals committed to our core values of quality, compassion and community! Shasta 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.
Shasta Regional Medical Center is a 226-bed acute care facility serving Northern California. The hospital offers a comprehensive range of services. Shasta Regional Medical Center is one of the nation’s 50 Top Cardiovascular Hospitals recognized by Watson Health and holds an ‘A’ Grade from Leapfrog Group, the nation's premier advocate of transparency in health care. The hospital is Joint Commission Certified for Stroke, Hip/Knee and Diabetes. They are a Five Star recipient for treatment of heart failure, respiratory failure and is named among the top 5% in the nation for patient safety. Shasta Regional Medical Center delivers patient-centered healthcare with compassion, dignity and respect for every patient and their family. For more information, visit www.shastaregional.com .
Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, ****** 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: https://www.eeoc.gov/sites/default/files/2026-10/EEOC_KnowYourRights_screen_reader_10_20.pdf
Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2026/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf
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. He/She will perform other duties as assigned or required.
Qualifications
EDUCATION, EXPERIENCE, TRAINING
Required Qualifications
• Medical Graduate, PA or Nursing Graduate
• Minimum of three (3) year’s clinical experience in an acute care setting
• Knowledge of care delivery documentation systems and related medical record documents
• Knowledge of age-specific needs and the elements of disease processes and related procedures
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes
• Excellent written, and verbal communication skills and critical thinking skills
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment
• Computer literacy and familiarity with the operation of basic office equipment
• Assertive personality traits to facilitate ongoing physician communication
Preferred Qualifications
• ECFMG Certificate or RN license
• Prior Case Management Experience
• Working knowledge of the Medicare reimbursement system and coding structures
• Current BCLS (AHA) certificate upon hire and maintain current
• ACLS Certificate
Shasta Regional Medical Center offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $28.00 to $43.40. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.
