company logo

56k - 86k USD/year

Office

Ontario, CA, United States

Full Time

Overview

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 51 hospitals and has more than 360 outpatient locations in 14 states providing more than 2.5 million patient visits annually. It is one of the nation’s leading health systems with nearly 57,000 employees and physicians. Eighteen of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team!

Responsibilities

The Clinical Documentation Specialist (CDS) is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records. These reviews are to evaluate whether the clinical documentation is reflective of the quality-of-care outcomes and reimbursement compliance for acute care services provided. The CDS works closely with the medical staff to facilitate appropriate clinical documentation of patient care. Other responsibilities include conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings. He/She will perform other duties as assigned or required.

Qualifications

Education and Work Experience

Required Qualifications:

  • Medical Graduate, PA or Nursing Graduate.
  • Minimum of 1+ years clinical experience in an acute care setting.
  • 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 pathology / physiology of disease processes.
  • Excellent written and verbal communication skills. Excellent critical thinking skills.
  • Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff.
  • Preferred Qualifications:

  • ECFMG Certificate or RN license 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.
  • Assertive personality traits to facilitate ongoing physician communication.
  • Working knowledge of Medicare reimbursement system and coding structures preferred.
  • Current BCLS (AHA) certificate upon hire and maintain current; preferred.
  • ACLS preferred
  • Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $28.00 to $43.40. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.

    Employment Status

    Full Time

    Shift

    Days

    Equal Employment Opportunity

    Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf

     

    Privacy Notice

    Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf

    CDS

    Office

    Ontario, CA, United States

    Full Time

    56k - 86k USD/year

    August 15, 2025

    company logo

    Prime Healthcare

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