Clinical Document Specialist

JPS Health Network • Fort Worth, TX

9d • Onsite

About The Position

The Clinical Documentation Specialist (CDS) is responsible for concurrently reviewing the medical records of hospitalized patients to facilitate the accurate and complete representation of severity of patient illness through provider documentation. This involves extensive record review, interaction with physicians, mid - levels, residents, nursing, ancillary staff, and coders.

Requirements

• Associate’s Degree in Nursing, Health Information Technology or a related field of study from an accredited college or university
• 2 plus years of relevant work experience in a hospital setting OR High School Diploma
• 2 plus years of relevant work experience in a hospital setting
• Minimum 2 years of experience in CDI or a related field
• If applicable team members in this job that hold a professional licensure or credentialed must keep licensure and credentials current.

Nice To Haves

• Bachelor’s Degree in Nursing, Health Information Technology or a related field of study from an accredited college or university
• 3 years of acute care clinical experience in a critical care or telemetry unit.
• Current Clinical Documentation Specialist certification through the Association of Clinical Documentation Improvement Specialists (ACDIS) and /or Clinical documentation Improvement Practitioner through the American Health Information Management Association (AHIMA).
• Current Medical Coding through AAPC, American Health Information Management Association (AHIMA) and / or through an organization accredited by the National Commission for Certifying Agencies (NCAA) for Medical Coding.

Responsibilities

• Identify new patient admissions and initiate review of documentation in the medical record utilizing clinical documentation software.
• Review documentation daily or at an interval appropriate to that patient’s clinical picture.
• Establish working Diagnosis – Related Group (DRG) based on assignment of International Classification of Disease (ICD) diagnosis and procedure codes.
• Identify opportunities to impact case mix through documentation of complicating and comorbid, or major complicating and comorbid conditions and formulate a provider query based on query guidelines with timely provider follow-up.
• Complete provider clarification queries per guidelines for instances in which documentation in the medical record is ambiguous, incomplete or conflicting and provide timely provider follow-up, as needed.
• Attend medical staff department meetings and present current clinical documentation trends, findings and provide education on the impacts of clinical documentation.
• Initiate Task Force meetings with the coding staff to discuss DRG assignment discrepancies and create participatory educational sessions regarding clinical conditions, documentation and coding.
• Performs other related job duties as assigned.

Benefits

• Health insurance
• Dental insurance
• Vision insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree