Clinical Documentation Specialist I Full Time Days BHS Westover - San Antonio, United States - Tenet Healthcare Corporation

Description

Summary

The Clinical Documentation Specialist I 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. 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. Completes established competencies for the position within designated introductory period. Other related duties as assigned.

Qualifications


MINIMUM EDUCATION:
Graduate of an accredited school of Nursing, AHIMA accredited school, United States or international school of medicine.


PREFERRED EDUCATION:
Bachelor's Degree in Health Information Management and/or Nursing or related healthcare Degree.


MINIMUM EXPERIENCE:

0-2 years of CDS experience and 2 years of recent acute care experience in a clinical or inpatient coding setting.

PREFERRED EXPERIENCE:
4 or more years of experience in acute care setting

REQUIRED CERTIFICATIONS/


LICENSURE:

RHIA, RHIT, CCS, CIC, Certified Documentation Specialist (CCDS), OR Certified Documentation Improvement Professional (CDIP), RN, LVN, LPN, MD, DO, PA, NP.

#LI-AP1

Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce.

If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date.

If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.