Prime Healthcare

Group CDS - SMRMC-MG Medical Records

Facility Saint Mary's Regional Medical Group
Business Professional
Position Type
Full Time


The Group Clinical Documentation Specialist (Group CDS) is responsible conducting clinically based concurrent and retrospective reviews of medical records. This review is to evaluate that the clinical documentation is reflective of quality of care outcomes and reimbursement compliance for acute care services provided. The Group CDS will work closely with the medical staff to facilitate appropriate clinical documentation of patient care. Other responsibilities include conducting documentation for Physician Quality Reporting Standards, CMS Meaningful Use Criteria on all selected visits and documenting findings.


Education and Work Experience

  1. Medical Graduate or Bachelors degree in Nursing/Clinical or related fields required. Masters degree in any healthcare related field preferred
  2. ECFMG Certificate preferred.
  3. 1+ year of clinical experience in acute care setting preferred.
  4. Minimum of two years experience with ICD-10 and CPT coding in an outpatient setting preferred.
  5. Basic computer experience required, experience in any EMR is preferred.
  6. Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm preferred
  7. Excellent written and verbal communication skills. Excellent critical thinking skills.
  8. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and management staff.
  9. Ability to work independently in a time-oriented environment.
  10. Familiarity with the operation of basic office equipments.

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources. EEO is the Law:


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