Clinical Documentation Specialist Health Information Management FT Days Baptist Health System San Antonio TX

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.

POSITION QUALIFICATIONS

MINIMUM EDUCATION: Associates Degree in Health Information Management and/or Graduate of an accredited school of Vocational Nursing, or 4 years of experience in lieu of education.

PREFERRED EDUCATION: Bachelors Degree in Health Information Management and/or Nursing

MINIMUM EXPERIENCE: 2 years of experience in acute care setting

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

REQUIRED CERTIFICATIONS/LICENSURE: RHIA, RHIA eligible, RHIT, RHIT eligible, CCS, Certified Documentation Specialist (CCDS), OR Certified Documentation Improvement Professional (CDIP) or possession of current Texas State license for Licensed Vocational Nurse.