A Clinical Documentation Specialist works with information technology systems and applications in health care organizations. Assists clinicians and staff with technology and implementing new systems. Creates systems for organizing and interpreting data and information for clinical trials. Records and manages clinical information about patients, including health assessments and diagnoses, test results, treatments, and follow up care requirements. Reviews and maintains patient records.
Overview We are seeking a dedicated and detail-oriented MDS Assessor to join our dynamic healthcare team. In this vital role, you will be responsible for conducting comprehensive assessments using the Minimum Data Set (MDS) to ensure accurate documentation and optimal patient care. Your expertise will support clinical decision-making, compliance with healthcare regulations, and quality improvement initiatives. This position offers an exciting opportunity to make a meaningful impact on patient outcomes through precise evaluation and documentation. Responsibilities Perform thorough MDS assessments for residents across various care settings, including long-term care facilities and skilled nursing homes. Review and analyze medical records, clinical documentation, and patient histories to ensure accuracy and completeness in accordance with clinical documentation standards. Collaborate with interdisciplinary teams to gather relevant information on patient status, physiology, and care plans. Ensure compliance with Centers for Medicare and Medicaid Services (CMS) regulations, HIPAA standards, and state healthcare policies during all assessment activities. Utilize electronic health record (EHR) systems such as Epic, Cerner, Athenahealth, or eClinicalWorks to document findings accurately and efficiently. Conduct documentation review for medical coding purposes, including
ICD-10/ICD-9/ICD
coding, CPT coding, DRG assignment, and utilization management. Support discharge planning, case management, and clinical documentation improvement efforts by providing detailed assessment reports. Experience Proven experience with MDS assessments in long-term care or skilled nursing environments. Strong knowledge of Medicare regulations, long-term care regulations, and NCQA standards related to clinical documentation. Experience working within hospital settings or acute care environments such as ICU or trauma centers is highly desirable. Familiarity with EMR/EHR systems like Epic, Cerner, Athenahealth, or eClinicalWorks is essential. Background in nursing, medical records management, or health information management is preferred. Critical care experience including ICU or emergency medicine enhances your ability to perform comprehensive assessments. Knowledge of medical terminology, anatomy, physiology, and healthcare regulations ensures precise evaluation and reporting. Join us in delivering exceptional patient care through meticulous assessment and documentation! This role is integral to maintaining compliance with healthcare standards while supporting the delivery of high-quality health services across diverse clinical settings.
Pay:
$73,645.00 - $105,000.00 per year
Benefits:
401(k) Dental insurance Employee discount Free parking Health insurance Paid time off Vision insurance
