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Clinical Documentation Specialist (CDS)

Overview

Join an award-winning team of dedicated professionals committed to our core values of quality, compassion and community! West Anaheim Medical Center, a member of Prime Healthcare, offers incredible opportunities to expand your horizons and be part of a community dedicated to making a difference. Founded in 1964, West Anaheim Medical Center is a 219-bed acute-care hospital dedicated to providing the community with high-quality, compassionate healthcare. Key services include general medical and surgical inpatient care and treatment, emergency services, surgical services, behavioral health, comprehensive heart center, and diagnostic imaging. For more information visit www.westanaheimmedctr.com.

 

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. The CDS will perform other duties as assigned or required.

Qualifications

EDUCATION, EXPERIENCE, TRAINING

 

1. Medical Graduate, PA or Nursing Graduate required2. Minimum of three one (1+) year’s clinical experience in an acute care setting3. Knowledge of care delivery documentation systems and related medical record documents4. Knowledge of age-specific needs and the elements of disease processes and related procedures5. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.6. Excellent written, and verbal communication skills and critical thinking skills.7. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.8. Working knowledge of inpatient admission criteria.9. Ability to work independently in a time-oriented environment.10. Computer literacy and familiarity with the operation of basic office equipment.11. Assertive personality traits to facilitate ongoing physician communication.12. ECFMG Certificate or RN license preferred.13. Prior Case Management Experience preferred.14. Working knowledge of the Medicare reimbursement system and coding structures preferred.15. Current BCLS (AHA) certificate upon hire and maintain current preferred.16. ACLS Certificate preferred.

 

 

Pay Transparency

West Anaheim Medical Center 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

 

Average salary estimate

$74256 / YEARLY (est.)
min
max
$58240K
$90272K

If an employer mentions a salary or salary range on their job, we display it as an "Employer Estimate". If a job has no salary data, Rise displays an estimate if available.

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Founded in 1964, West Anaheim Medical Center is a 219-bed acute-care hospital dedicated to providing the community with high-quality, cost-effective healthcare. Our services include general medical/surgical inpatient care and treatment, emergency ...

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Full-time, onsite
DATE POSTED
October 15, 2025
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