IDR, Inc.

IDR is seeking a dedicated and experienced Clinical Documentation Specialist to join one of our top clients in California. 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
• CCDS or CDIP CERTIFIED 

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