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Universal Health Services

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Universal Health Services
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Job Details

Deltek Talent Management - CLINICAL DOCUMENTATION COORD - (6621)

Job Details


Facility Name
Palmdale Regional Medical Center
PALMDALE, CA 93551 US (Primary)
Career Area
Allied Health
Compliance, Other, Registered Nurse (RN), Support Staff
Job Description


Responsible for improving the overall quality and completeness of clinical documentation.  Promotes a partnership between the concurrent clinical reviews, medical record coders, and physicians to improve documentation and reimbursement for PRMC.  Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians, advocating for appropriate reimbursement.  Responsible for reviewing medical records to identify payer population as documented upon admission and throughout the hospitalization.  Analyzes status of patient, current treatment plan, past medical history and identified possible gaps in physician documentation.  Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patient’s true severity of illness, intensity of care, and risk of mortality.  Educates all members of the healthcare team on an ongoing basis.

Job Requirements


Work Experience: Minimum of 5 years recent clinical experience in an acute care setting required. Critical care of medical/surgical preferred.

Education: Associates Degree required.

License, Certification, or Registration required: Registered Nurse or International Medical Graduate (IMG)


In Lieu of above Education/License, Certification, or Registration requirements: Bachelors of Science Degree and Minimum of 5 years recent clinical experience in an acute setting required. Critical care of medical/surgical preferred.

Other Qualifications to include:

  • 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 anatomy and pathology/physiology of disease processes.
  • Good command of the English language with excellent written and verbal communication skills at all levels.
  • Excellent critical thinking skills required.
  • Demonstrate good nurse-physician relationships in the past and has the ability to maintain those going forward.
  • Working knowledge of current ICD-10-CM/PCS coding guidelines, with working knowledge of Medicare reimbursement system preferred.
  • 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.  Proficiency in the use of computers and software applications, which includes CERNER, 3M, CDIS program.  Knowledge in Microsoft Office applications such as: Excel, Work, Outlook and Power Point.
  • Assertive personality traits to facilitate ongoing physician communication.
  • Ability to stand and walk for periods of time is required in the performance of job responsibilities. 
  • Detailed oriented, ability to collect, trend and report data.
  • Excellent organizational skills required.
  • Ability to perform under pressure, meet frequent deadlines and tight schedules.
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