Clinical Documentation Specialist - Peri-Operative

Job Summary

The peri-operative Clinical Documentation Specialist role (CDS) is a hybrid role combining clinical documentation and case management expertise. The primary purpose of this role is to have a comprehensive, systematic approach to a patient’s health record before, during, and after surgery, with an emphasis on patient and record optimization. The role is a specialized position that combines oversight of the medical record with coordination of patient care focusing on regulatory compliance, improving patient outcomes, and managing healthcare resources efficiently. The role simultaneously manages patient cases, ensuring complete and accurate medical record documentation for coding and reimbursement, while collaborating with the healthcare team to improve quality of care and documentation. The CDS is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. The peri-operat...