Sutter Health Clinical Documentation Specialist, Quality Management in Burlingame, California

Position Overview:

The Clinical Documentation Specialist (CDS) performs concurrent review and analysis of the clinical documentation in the medical recordand collaborates with physicians, nursing, Case Management and HIM coding staff to assure appropriate documentation of severity of illness (SOI), risk of mortality (ROM), APR and MS-DRG classification.Assists in the education of the Professional Staff and other caregivers relating to clarity and completeness of documentation.

Actively works in support of regulatory compliance assuring that MPHS maintains full accreditation and compliance with state and federal regulations.Understands specific responsibilities for regulatory compliance in the home department and insures daily requirements for compliance are met.

  • Conducts initial concurrent review and subsequent reviews for all selected admissions. Makes independent assessments based on advanced clinical knowledge of diagnoses, comorbidities and complications.Also identifies other key quality indicators as needed. Identifies and records principal and secondary diagnoses, principal procedures and assigns a working DRG.

  • Collaborates with physicians, nurses, clinical care providers, and Health Information Management (HIM) coders to clarify or add documentation as needed.Utilizes various methods to obtain clear and specific documentation, including but not limited to written queries in the electronic health record (EHR) and discussions in person and by telephone.Proactively solicits physician responses to clarification requests. Acts as an intermediary between physicians and coders. Effectively deals with resistance and conflict with members of the patient care team, physicians, case management and HIM.


  • Bachelor's Preferred in Nursing or other Health care related field or equivalent experience is required.

  • Must maintain current knowledge of coding guidelines and required continuing education hours in nursing and/or coding

  • Registered Nurse - State Licensure - RN ORRegistered Health Information Administrator - RHIA ORRegistered Health Information Technician - RHIT ORCertified Coding Specialist - CCS ORCertified Clinical Documentation Specialist - CCDS ORValid clinical license and/or certification as appropriate to clinically assess medical records and communicate clinical detail required.

  • Minimum of 3-5 years clinical experience in an acute care setting required

  • For RHIA, RHIT, or CCS, CCDS, minimum of recent 5 years inpatient coding experience in an acute care setting required

  • Broad acute clinical background with experience in more than one population preferred.

  • Working knowledge of coding, APR and MS-DRG assignment process is preferred.

Organization: Mills-Peninsula Health Services

Employee Status: Regular

Employee Referral Bonus: No

Benefits: Yes

Position Status: Exempt

Union: No

Job Shift: Day

Shift Hours: 8 Hour Shift

Days of the Week Scheduled: Monday-Friday

Weekend Requirements: None

Schedule: Full Time

Hrs Per 2wk Pay Period: 80

All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, marital status, sexual orientation, registered domestic partner status, sex, gender, gender identity or expression, ancestry, national origin (including possession of a driver's license issued to individuals who did not present proof of authorized presence in the U.S.), age, medical condition, physical or mental disability, military or protected veteran status, political affiliation, pregnancy or perceived pregnancy, childbirth, breastfeeding or related medical condition, genetic information or any other characteristic made unlawful by local, state, or federal law, ordinance or regulation. External hires must pass a background check/drug screening. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state, and local laws, including but not limited to the San Francisco Fair Chance Ordinance.