Clinical Documentation Specialist II

Tenet Healthcare Corporation • San Antonio, TX

9h

About The Position

The Clinical Documentation Specialist II improves the quality and completeness of clinical documentation. The role conducts concurrent reviews of selected admissions and documents findings, then works with physicians, case management, nursing staff, other patient caregivers, and health information management coding staff to ensure documentation accurately reflects patient severity of illness and risk of mortality. The specialist ensures clinical information used to measure and report physician and hospital outcomes is accurate and complete, maintains review records in accordance with departmental and regulatory guidelines, and complies with medical-record confidentiality policies and procedures.

This is an intermediate-level role for an experienced Clinical Documentation Specialist. The specialist demonstrates the skills of a CDS I with an error rate below 5%, serves as an educator for other specialists and a senior team leader, identifies operational improvement opportunities, and participates in program meetings, physician and staff education, staff development, departmental activities, and in-service opportunities. The position also includes completing established competencies within the designated introductory period and performing other related duties as assigned.

Requirements

• Graduate of an accredited school of Nursing, an AHIMA-accredited school, or a United States or international school of medicine.
• 2–5 years of Clinical Documentation Specialist experience in an acute care setting.
• One of the following required certifications, licenses, or credentials: RHIA, RHIT, CCS, CCDS, CDIP, RN, LVN, LPN, MD, DO, PA, or NP.
• Demonstrate the skills of a CDS I with an error rate below 5%.

Nice To Haves

• Bachelor’s degree in Health Information Management, Nursing, or another healthcare-related field.
• 6 or more years of experience in an acute care setting.

Responsibilities

• Conduct concurrent record reviews on selected admissions and document findings.
• Facilitate modifications to clinical documentation so it accurately reflects patient severity of illness and risk of mortality.
• Collaborate extensively with physicians, case management, nursing staff, other patient caregivers, and health information management coding staff.
• Ensure clinical information used to measure and report physician and hospital outcomes is accurate and complete.
• Maintain accurate records of review activities in compliance with departmental and regulatory agency guidelines.
• Follow policies and procedures related to the confidentiality of medical records.
• Educate other specialists and serve as a senior team leader in the department.
• Identify opportunities for interdepartmental and intradepartmental operational improvements.
• Participate in program-related meetings, physician and staff education, staff development, departmental activities, and in-service opportunities.
• Complete established competencies within the designated introductory period and perform other related duties as assigned.

Benefits

• Medical, dental, vision, and life insurance.
• 401(k) retirement savings plan with employer match.
• Paid time off.
• Career development and continuing education opportunities.
• Health savings accounts and healthcare and dependent flexible spending accounts.
• Employee Assistance Program.
• Employee discount program.
• Voluntary benefits including pet insurance, legal insurance, accident and critical illness insurance, long-term care, elder and childcare, and auto and home insurance.
• The position may qualify for a sign-on bonus.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed