Clinical Documentation Specialist

3 weeks ago

San Antonio, United States CHRISTUS Santa Rosa Hospital Medical Center 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

  • Clinical Documentation Specialist

    2 weeks ago

    San Antonio, 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

    2 weeks ago

    San Antonio, 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

    2 weeks ago

    San Antonio, 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

    3 weeks ago

    San Antonio, United States CHRISTUS Childrens Hospital 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...

  • Clinical Documentation Specialist

    7 days ago

    San Antonio, United States Christus Health Full time

    **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 assignment and...

  • Clinical Documentation Specialist

    2 weeks ago

    San Antonio, 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

    2 weeks ago

    San Angelo, United States Shannon Health Full time

    Job SummaryThe clinical documentation specialist works collaboratively with physician and coding staff to ensure that the documentation in the medical record accurately reflects the quality and level of care provided. The overall goal of the position is to improve clinical documentation for quality assurance and revenue compliance and integrity.Scope &...

  • Clinical Documentation Specialist

    1 week ago

    San Diego, United States Ladgov Corporation Full time

    Job DescriptionJob DescriptionJob title: Clinical Documentation Specialist Location:San Diego, CA Schedule:Monday through Friday 7:30 am to 4:00 pm.Duties:Abstract medical record data and assign codes.Improve quality and accuracy of medical record documentation.Develop and update policy memoranda on documentation.Serve as technical expert in health record...

  • Clinical Recruitment Specialist l

    1 week ago

    San Antonio, United States Worldwide Clinical Trials - USA Full time

    Who we are We’re a global, midsize CRO that pushes boundaries, innovates and invents because the path to a cure for the world’s most persistent diseases is not paved by those who play it safe. It is built by those who take pioneering, creative approaches and implement them with quality and excellence. We are Worldwide Clinical Trials, and we are a...

  • Clinical Documentation Specialist

    7 days ago

    San Diego, United States Ladgov Corporation Full time

    Job title: Clinical Documentation Specialist Location:San Diego, CA Schedule:Monday through Friday 7:30 am to 4:00 pm.Duties:Abstract medical record data and assign codes.Improve quality and accuracy of medical record documentation.Develop and update policy memoranda on documentation.Serve as technical expert in health record content.Perform reviews, analyze...

  • Clinical Documentation Specialist

    1 week ago

    San Antonio, TX, 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 Research Coordinator III

    3 weeks ago

    San Antonio, United States DM Clinical Research Full time

    Job DescriptionJob DescriptionClinical Research Coordinator IIIA CRC III will ensure that quality research is conducted at assigned investigative sites in accordance with the sponsor protocol, FDA Regulations, and ICH/GCP guidelines and to provide the best quality data to the sponsor. To ensure study enrollment meets or exceeds Sponsors' expectations. To...

  • Clinical Research Coordinator II

    3 weeks ago

    San Antonio, United States DM Clinical Research Full time

    Job DescriptionJob DescriptionClinic Research Coordinator II The Clinical Research Coordinator II, will ensure that quality research is conducted at the assigned investigative sites in accordance with the sponsor protocol, FDA Regulations, and ICH/GCP guidelines and to provide the best quality data to the sponsor. The CRC I will also ensure study...

  • Clinical Informatics Systems Specialist

    16 hours ago

    San Antonio, United States START Center for Cancer Research Full time

    Job DescriptionJob DescriptionThe Clinical Informatics System Specialist (CISS) exists to ensure that new protocols are configured completely and accurately in the CTMS system, to support clinical teams in protocol execution and management. Specifically, this role will translate clinical trial Schedule of Assessments (SOE) - through conversations with...

  • Unblinded Clinical Research Coordinator III

    3 weeks ago

    San Antonio, United States DM Clinical Research Full time

    Job DescriptionJob DescriptionUnblinded Clinical Research Coordinator IIIUnblinded CRC III will be responsible for dispensing Investigational Products (IP) as part of clinical research trials.DUTIES & RESPONSIBILITIESLead Unblinded team operations Compound and dispense prescribed IP as needed by Sponsor approved protocol.     Supervise and maintain...

  • Clinical Procurement Specialist

    4 weeks ago

    San Antonio, Texas, United States Evidence in Motion Full time

    Overview: Summary: At EIM we are reimagining healthcare education to make accessible education for everyone! The Clinical Procurement Specialsit will play a pivotal role in the success of EIM’s mission by identifying and developing new partnerships with leading hospitals and clinics. The Clinical Procurement Specialist will elevate and transform EIM’s...

  • Clinical Document Specialist Case Manager

    4 weeks ago

    San Bernardino, California, United States Dignity Health Full time

    OverviewFounded in 1910 Dignity Health - Community Hospital of San Bernardino is a 347-bed acute care nonprofit community hospital located in San Bernardino California. Known for its programs in maternity care and pediatrics behavioral health and long-term subacute care for adults and children the hospital also includes inpatient and outpatient surgery. The...

  • Clinical Pharmacist Specialist BMT Onc

    16 hours ago

    San Antonio, Texas, United States HCA Healthcare Full time

    Description IntroductionDo you have the career opportunities as a(an) Clinical Pharmacist Specialist BMT Onc you want with your current employer? We have an exciting opportunity for you to join Methodist Hospital which is part of the nations leading provider of healthcare services, Methodist Healthcare.BenefitsMethodist Hospital, offers a total rewards...

  • Clinical Document Specialist Case Manager

    4 weeks ago

    San Bernardino, California, United States CommonSpirit Health Full time

    Overview: Founded in 1910 Dignity Health - Community Hospital of San Bernardino is a 347-bed acute care nonprofit community hospital located in San Bernardino California. Known for its programs in maternity care and pediatrics behavioral health and long-term subacute care for adults and children the hospital also includes inpatient and outpatient surgery....

  • Clinical Pharmacist Specialist Critical Care

    4 weeks ago

    San Antonio, Texas, United States HCA Full time

    Jump-start your career as a(an) Clinical Pharmacist Specialist Critical Care today with Methodist Hospital.Referral services for child, elder and pet care, home and auto repair, event planning and moreYou will lead and develop pharmacy clinical services such as drug consults, nutrition support, pharmacokinetics, anticoagulant monitoring, pain management, IV...