Job Description

Description We are welcoming a Clinical Documentation Review Specialist to join our healthcare team in Rancho Cordova, California. This role involves a meticulous examination of hospital medical documentation, communication with medical staff, and ensuring appropriate reimbursement for the hospital reflecting the complexity and severity of patient care. Responsibilities: - Evaluate medical record documentation concurrently on the nursing units to guarantee clear and comprehensive documentation by physicians. - Engage with physicians concerning missing, unclear, or conflicting medical record documentation and secure additional documentation within the medical record to assist with the correct code assignment. - Offer documentation and coding education to patient care providers. - Participate in retrospective chart reviews to assess the effectiveness of physician prompting. - Contribute to the analysis and trending of statistical data for specified patient populations to identify areas for improvement. - Ensure accurate completion of worksheets for performance tracking reports. - Make decisions about the interpretation and clarification of inpatient documentation and determine when to prompt physicians for more complete documentation affecting hospital reimbursement. - Accurately and effectively identify missing documentation through clinical review and communicate with physicians and patient care teams regarding additional or more complete documentation opportunities. - Manage compliance with Medical Staff Rules and Regulations regarding documentation requirements, understanding coding and legal guidelines established by external regulatory agencies and following state and organization patient confidentiality policies. Requirements - Minimum of 5 years of experience in a healthcare setting, preferably within the NHS. - Demonstrable skills in Auditing, particularly within a healthcare context. - Proficiency in Health Information Management (HIM). - Experience with Electronic Medical Records (EMR) is essential. - Ability to perform Medical Records Analysis and Medical Records Review effectively. - Familiarity with Clinical Data Interchange Standards Consortium (CDISC) protocols. - Knowledge of All Patient Refined Diagnosis Related Groups (APR DRG) and All Patient Diagnosis Related Groups (AP-DRGs) is required. - Experience with Health Care Audits, specifically within the Medicare and Medicaid systems. - Comprehensive understanding of Medicare regulations and guidelines. TalentMatch® Robert Half is the world's first and largest specialized talent solutions firm that connects highly qualified job seekers to opportunities at great companies. We offer contract, temporary and permanent placement solutions for finance and accounting, technology, marketing and creative, legal, and administrative and customer support roles. Robert Half works to put you in the best position to succeed. We provide access to top jobs, competitive compensation and benefits, and free online training. Stay on top of every opportunity - whenever you choose - even on the go. Download the Robert Half app ( and get 1-tap apply, notifications of AI-matched jobs, and much more. All applicants applying for U.S. job openings must be legally authorized to work in the United States. Benefits are available to contract/temporary professionals, including medical, vision, dental, and life and disability insurance. Hired contract/temporary professionals are also eligible to enroll in our company 401(k) plan. Visit roberthalf.gobenefits.net for more information. © 2025 Robert Half. An Equal Opportunity Employer. M/F/Disability/Veterans. By clicking "Apply Now," you're agreeing to Robert Half's Terms of Use ( .

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Permanent employment, Contract work, Temporary work,

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