Clinical Documentation Specialist II

Tenet Healthcare Corporation • San Antonio, TX

1d • Onsite

About The Position

The Clinical Documentation Specialist II is responsible for improving overall quality and completeness of clinical documentation. Performs concurrent record reviews on all selected admissions and documents findings. Facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management, nursing staff, other patient care givers and health information management coding staff. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Maintains accurate record of review activities to comply with departmental and regulatory agency guidelines. Understands and complies with policies and procedures related to confidentiality of medical records. Serves as a department educator for other specialists and as a senior team leader in the department. Identifies opportunities for interdepartmental and intradepartmental operational improvements. Participates in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities. Intermediate level position for experienced CDS. Demonstrates all skills of CDS I with <5% error rate. Completes established competencies for the position within designated introductory period. Other related duties as assigned.

Requirements

• Demonstrates all skills of CDS I with <5% error rate.
• Completes established competencies for the position within designated introductory period.

Nice To Haves

• Intermediate level position for experienced CDS.

Responsibilities

• Improving overall quality and completeness of clinical documentation.
• Performing concurrent record reviews on all selected admissions and documenting findings.
• Facilitating modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management, nursing staff, other patient care givers and health information management coding staff.
• Ensuring the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
• Maintaining accurate record of review activities to comply with departmental and regulatory agency guidelines.
• Serving as a department educator for other specialists and as a senior team leader in the department.
• Identifying opportunities for interdepartmental and intradepartmental operational improvements.
• Participating in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities.

Benefits

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

What This Job Offers

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