Clinical Documentation Specialist

2 weeks ago

Tyler, United States Christus Health Full time
Description

Summary:

The Clinical Documentation Specialist (CDS) position isresponsible for facilitating improvement in the overall quality andcompleteness of the medical record documentation. The CDS willprovide support and expertise through comprehensive assessment andreview of inpatient medical records. The CDS will facilitateaccurate DRG assignment and obtain appropriate documentationthrough extensive interaction with physicians, patient caregiversand health information management coding staff to ensure thatreimbursement are received for the level of services rendered tothe patients.

  • Analyzes clinicalstatus of patient, current treatment plan and past medical historyand identifies potential gaps in physiciandocumentation.
  • Communicates with attendingphysician either verbally or through written methodology tovalidate observations and suggest additional and/or more specificdocumentation.
  • Maintains positivecommunication with physicians, nursing and all other disciplinesinvolved in the care of the patient.
  • Worksclosely with HIM Coding staff to assure documentation of dischargediagnosis and any co-existing co-morbidities are a completereflection of the patient’s clinical status andcare.
  • Maintains an electronic DRG worksheet toassist coders on identifying all documented diagnosis andprocedures.
  • Updates DRG worksheet to reflectany changes to inpatient status/procedure/treatment and conferswith the physician to finalize diagnosis.
  • Consistently meets established productivity targets for recordreview.
  • Designs and implements incollaboration with physician leadership specific tools to supportmedical record physician documentation.
  • Develops and implements plans for both formal and informaleducation of physician, nursing, and other clinical staff onclinical documentation opportunities, coding and reimbursement aswell as performance improvement methodologies.
  • Assists in collection and organization of data for analysis byappropriate medical and hospital committees.
  • Identifies strategies for sustained work process changes thatfacilitate complete accurate clinicaldocumentation.
  • Demonstrates competence toperform assigned responsibilities in a manner that meets thepopulation-specific and developmental needs of the members servedby the department.
  • Appropriately adaptsassigned assessment, treatment, and/or service methods toaccommodate the unique physical, psychosocial, cultural,age-specific and other developmental needs of each memberserved.
  • Takes personal responsibility toensure compliance with all policies, procedures and standards aspromulgated by state and federal agencies, the hospital, and otherregulatory entities.
  • Performs all duties in amanner that protects the confidentiality of the patient and doesnot solicit or disclose any confidential information unless it isnecessary in the performance of assigned jobduties.
  • Performs other duties asassigned.

Requirements:

  • Registered Health Information ManagementAdministrator (RHIA) or Technician (RHIT) graduate of an approvedcollege program for Health Information Management or graduate ofthe American Medical Record Associate’s Independent Study Coursefor Medical Record Technicians is required.
  • College courses in medical terminology and anatomy and physiologypreferred.
  • Must be efficient and completelyaccurate in performance of coding tasks.
  • Mustbe able to accurately read and decipher handwriting that isdifficult to read.
  • Handwriting of alphabet andnumbers must be neat and legible.
  • Must be ableto work with speed and accuracy and with good eye-handcoordination.
  • Must be able to operate computerterminal and other office machines.
  • Must beknowledgeable of the application of the InternationalClassification of Diseases and Operations, Ninth Revision, ClinicalModification, (ICD-9-CM/ICD-10-CM), and Current ProceduralTerminology (CPT), Diagnosis Related Groups (DRG) and AmbulatoryPayment Classifications (APC).
  • Must befamiliar with content and arrangement of the medicalrecord.
  • Must be familiar with the otherfunctions in Medical Records and how they relate to the Codingfunction.
  • A minimum of 5 years in area ofpopulation to be served is required.
  • Three (3)years pervious acute hospital inpatient coding experiencerequired.
  • Case Management / UtilizationManagement and discharge planning experiencepreferred.
  • Must possess a good background inmedical terminology and anatomy and physiology as the fundamentalof medical science.
  • Registered HealthInformation Management Administrator Technician (RHIT)required
  • Registered Health InformationManagement Administrator (RHIA)preferred
  • Certified Inpatient Coding Specialist(CCDS) highly preferred; if not certified must be eligible to takeone of the abovementioned exams and must obtain credentials /certifications within 12 months of hiring date. Certified InpatientCoding Specialist (CCS) required within 12 months ofhire
  • Certified Inpatient Coding Specialist(CCS) required within 12 months of hire
  • CDScertification preferred

Work Type:

Part Time


  • Clinical Documentation Specialist

    5 days ago

    Tyler, United States Impresiv Health Full time

    Title: Clinical Documentation Specialist Description: The PRN Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The PRN CDS will provide support and expertise on a temporary basis through comprehensive assessment and review of...

  • Clinical Documentation Specialist

    4 weeks ago

    Tyler, United States Christus Health Full time

    Job DescriptionSummary:The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG...

  • Clinical Documentation Specialist

    4 weeks ago

    Tyler, United States Christus Health Full time

    DescriptionSummary: The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG assignment...

  • Clinical Documentation Specialist

    4 days ago

    Tyler, United States Christus Health Full time

    Job Description Summary: The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG...

  • Clinical Documentation Specialist

    4 weeks ago

    Tyler, TX, United States Christus Health Full time

    DescriptionSummary: The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG assignment...

  • Clinical Documentation Specialist

    4 weeks ago

    Tyler, United States Christus Health Full time

    Job DescriptionSummary:The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG...

  • Clinical Informatics Specialist

    2 weeks ago

    Tyler, United States Oak Street Health Full time

    Company: Oak Street Health Title: Clinical Informatics Specialist Location: Various Oak Street Health is a rapidly growing, innovative company of community-based healthcare centers delivering higher quality health and wellness care that improves outcomes, manages medical costs and provides an unmatched experience for adults on Medicare in medically...

  • Clinic Manager

    3 weeks ago

    Tyler, United States Ardent Health Services Full time

    Overview Join our team as a full-time Pulmonary Specialists Clinic Manager in Tyler, TX. Fulfilling your purpose begins here: People First, Always. Here's how we take care of our people: * Medical, vision, dental health insurance, health savings account / flexible spending, competitive pay, paid time off, 401k retirement plan with company match, employee...

  • Hospital Practice Specialist I

    1 week ago

    Tyler, United States SCP Health Full time

    DescriptionAt SCP Health, what you do matters.As part of the SCP Health team, you have an opportunity to make a difference. At our core, we work to bring hospitals and healers together in the pursuit of clinical effectiveness. With a portfolio of over 8 million patients, 7500 providers, 30 states, and 400 healthcare facilities, SCP Health is a leader in...

  • Clinic Supervisor-Overton Clinic

    5 days ago

    Tyler, United States University of Texas At Tyler Full time

    Job Summary: The Supervisor provides administrative support to day-to-day operations within assigned clinic/department by using critical thinking skills to make a variety of decisions. Major Responsibilities / Duties / Critical Tasks: * Supervises front end staff by communicating, training and displaying the kind of work example others wish to follow...

  • Registered Nurse

    2 months ago

    Tyler, United States UT Health Tyler Full time

    OverviewJoin our team as a full-time, day shift, Clinical Educator Registered Nurse in Tyler, TX.  Fulfilling your purpose begins here: People First, Always. Here’s how we take care of our people:Medical, vision, dental health insurance, health savings account / flexible spending, competitive pay, paid time off, 401k retirement plan with company match,...

  • Registered Nurse

    1 month ago

    Tyler, United States UT Health Tyler Careers Full time

    OverviewJoin our team as a full-time, day shift, Clinical Educator Registered Nurse in Tyler, TX.  Fulfilling your purpose begins here: People First, Always. Here’s how we take care of our people:Medical, vision, dental health insurance, health savings account / flexible spending, competitive pay, paid time off, 401k retirement plan with company match,...

  • Registered Nurse

    1 month ago

    Tyler, United States UT Health Tyler Careers Full time

    OverviewJoin our team as a full-time, day shift, Clinical Educator Registered Nurse in Tyler, TX.  Fulfilling your purpose begins here: People First, Always. Here’s how we take care of our people:Medical, vision, dental health insurance, health savings account / flexible spending, competitive pay, paid time off, 401k retirement plan with company match,...

  • Registered Nurse

    1 month ago

    Tyler, United States UT Health Tyler Full time

    OverviewJoin our team as a full-time, day shift, Clinical Educator Registered Nurse in Tyler, TX.  Fulfilling your purpose begins here: People First, Always. Here’s how we take care of our people:Medical, vision, dental health insurance, health savings account / flexible spending, competitive pay, paid time off, 401k retirement plan with company match,...

  • Registered Nurse

    2 months ago

    Tyler, United States UT Health Tyler Full time

    OverviewJoin our team as a full-time, day shift, Clinical Educator Registered Nurse in Tyler, TX. Fulfilling your purpose begins here: People First, Always. Here’s how we take care of our people:Medical, vision, dental health insurance, health savings account / flexible spending, competitive pay, paid time off, 401k retirement plan with company match,...

  • Registered Nurse

    1 month ago

    Tyler, United States UT Health Tyler Full time

    OverviewJoin our team as a full-time, day shift, Clinical Educator Registered Nurse in Tyler, TX.  Fulfilling your purpose begins here: People First, Always. Here’s how we take care of our people:Medical, vision, dental health insurance, health savings account / flexible spending, competitive pay, paid time off, 401k retirement plan with company match,...

  • Clinic RN

    5 days ago

    Tyler, United States US Oncology, Inc Full time

    Clinic RNOverview Texas Oncology is looking for a Full-time Clinic Registered Nurse (RN) to join our team! This position will support the Tyler location. This is a full-time Monday-Friday 8:30am-5pm position with no weekends, call, or major holidays. This position can be a level 1, 2, or Sr based on candidate experience. Notes from hiring manager: We have...

  • Clinical Research Coordinator

    4 days ago

    Tyler, United States US Oncology, Inc. Full time

    Overview Texas Oncology is looking for a Clinical Research Coordinator to join our team!  This position will support the Tyler location. This is a full-time Monday - Friday 8am-5pm position with no weekends, call, or major holidays. This position can be a level 1, 2 or Sr based on candidate experience Texas Oncology is the largest community...

  • Clinical Informatics Analyst

    4 weeks ago

    Tyler, United States Ardent Health Services Full time

    Overview Join our team as a day shift, full-time, Clincal Informatics Analyst with our Ambulatory Care Team in Tyler, TX. Fulfilling your purpose begins here: People First, Always. Here's how we take care of our people: * Medical, vision, dental health insurance, health savings account / flexible spending, competitive pay, paid time off, 401k retirement...

  • Clinical Informatics Analyst

    4 days ago

    Tyler, United States Ardent Health Services Full time

    Overview Join our team as a day shift, full-time, Clinical Informatics Analyst in Tyler, TX. Fulfilling your purpose begins here: People First, Always. Here's how we take care of our people: * Medical, vision, dental health insurance, health savings account / flexible spending, competitive pay, paid time off, 401k retirement plan with company match,...