Clinical Documentation Specialist

3 weeks ago

San Antonio, United States Christus Health Full time
Job Description

Summary:

The 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 and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement is received for the level of services rendered to the patients.

CHRISTUS Santa Rosa Hospital - Medical Center (CSRH-MC), located in the South Texas Medical Center, provides a high-level of care through compassionate hands, experience physicians, and advanced technology, including the da Vinci Surgical Robot System and the Mako™ Robotic-Arm Assisted System. Services at the 178- bed facility include Acute Care of the Elderly Unit, cardiology, diabetes care, emergency care, general surgery, kidney transplantation at the CHRISTUS Transplant Institute, orthopedics, outpatient rehabilitation and aquatic therapy, Senior Behavioral Health Center, urology, and the Wound Care and Hyperbaric Center.

Requirements:

Registered Health Information Management Administrator (RHIA) or Technician (RHIT) graduate of an approved college program for Health Information Management or graduate of the American Medical Record Associate’s Independent Study Course for Medical Record Technicians is required.
Certified Inpatient Coding Specialist (CCDS) highly preferred
If not certified must be eligible to take one of the above mention exams, and must obtain credentials / certifications within 12 months of hiring date.
College courses in medical terminology and anatomy and physiology preferred.
Must be efficient and completely accurate in performance of coding tasks.
Must be able to accurately read and decipher handwriting that is difficult to read.
Handwriting of alphabet and numbers must be neat and legible.
Must be able to work with speed and accuracy and with good eye-hand coordination.
Must be able to operate computer terminal and other office machines.
A minimum of 5 years in area of population to be served is required.

Case Management / Utilization Management and discharge planning experience preferred.
Three (3) years pervious acute hospital inpatient coding experience required.
Must possess a good background in medical terminology and anatomy and physiology as the fundamental of medical science.
Must be knowledgeable of the application of the International Classification of Diseases and Operations, Ninth Revision, Clinical Modification, (ICD-9-CM/ICD-10-CM), and Current Procedural Terminology (CPT), Diagnosis Related Groups (DRG) and Ambulatory Payment Classifications (APC).
Must be familiar with content and arrangement of the medical record.
Must be familiar with the other functions in Medical Records and how they relate to the Coding function.
Registered Health Information Management Administrator (RHIA) preferred

Registered Health Information Management Administrator Technician (RHIT) required
Certified Inpatient Coding Specialist (CCS) required within 12 months of hire
CDS certification preferred

Work Type:

Per Diem As Needed
Req. No

131444

Job Title

Clinical Documentation Specialist - Medical Records - PRN

Market

CHRISTUS Santa Rosa

Category

Revenue Cycle

Facility

CHRISTUS Santa Rosa Hospital Medical Center

Address

2827 Babcock Road
San Antonio, TX 78229
US

Type

PRN

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