Clinical Documentation Specialist (CDS) 3.3 3.3 out of 5 stars San Francisco, CA 94109 • Hybrid work InSync Consulting is seeking a Clinical Documentation Specialist (CDS) with a strong clinical background to facilitate accurate and complete clinical documentation in the medical record. This role requires extensive record review and collaboration with physicians, allied health professionals, health information management teams, and nursing staff to ensure the medical record reflects the true clinical picture of the patient . The CDS will support the organization by utilizing a concurrent review process to enhance documentation accuracy and compliance with MS-DRG classification , in alignment with CMS regulations . Case reviews will be prioritized based on organizational needs and may include APR-DRG classification accuracy, Quality Data elements (e.g., Patient Safety Indicators, Readmissions, and Mortality Reviews), and Risk Adjustment tools .

Key Responsibilities:

Conduct comprehensive clinical record reviews to ensure accurate and complete documentation. Collaborate with physicians, nurses, and healthcare professionals to improve documentation clarity. Apply MS-DRG classification to ensure compliance with CMS guidelines . Utilize quality-based review processes, mortality reviews, and risk adjustment tools . Assist in educating providers and clinical staff on documentation best practices. Work in a hybrid capacity (50% onsite, 50% remote) while maintaining strong communication in a remote team setting.

Requirements:

Medical degree (IMG) or RN license. At least 2 years of Clinical Documentation Improvement (CDI) experience in a complex acute care setting.

Preferred experience in:

OBGYN, Pediatrics, and Inpatient Psychiatry. Quality-based reviews, mortality reviews, and risk adjustment tools. Strong communication skills with the ability to collaborate effectively in a remote team environment.

Job Types:

Full-time, Contract Pay:

$58.73 - $62.25 per hour Expected hours: 40 per week

Benefits:

Health insurance

Schedule:

8 hour shift Day shift

Experience:

Clinical Documentation Improvement:

2 years (Required)

OBGYN, Pediatric, or Inpatient Psychiatric:

1 year (Preferred)

License/Certification:

RN License (Required) Ability to

Commute:

San Francisco, CA 94109 (Required)

Work Location:

Hybrid remote in San Francisco, CA 94109