The Clinical Documentation Specialist is responsible for improving overall quality and completeness of clinical documentation. Performs concurrent record reviews on all selected admissions and documents findings. The Clinical Documentation Specialist 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. The Clinical Documentation Specialist 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. The Clinical Documentation Specialist understands and complies with policies and procedures related to confidentiality of medical records. Identifies opportunities for interdepartmental and intradepartmental operational improvements. The Clinical Documentation Specialist participates in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities. The Clinical Documentation Specialist completes established competencies for the position within designated introductory period. Other related duties as assigned.
Education 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
Experience MINIMUM EXPERIENCE: 2 years of experience in acute care setting PREFERRED EXPERIENCE: 4 or more years of experience in acute care setting
Licensure/Certification 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.
Job: Medical Records
Primary Location: San Antonio, Texas
Facility: Baptist Health System
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 2105023492
About Baptist Health System
Tenet Healthcare Corporation (NYSE: THC) is a diversified healthcare services company headquartered in Dallas with 112,000 employees. Through an expansive care network that includes United Surgical Partners International, we operate 65 hospitals and approximately 510 other healthcare facilities, including surgical hospitals, ambulatory surgery centers, urgent care and imaging centers and other care sites and clinics. We also operate Conifer Health Solutions, which provides revenue cycle management and value-based care services to hospitals, health systems, physician practices, employers and other clients. Across the Tenet enterprise, we are united by our mission to deliver quality, compassionate care in the communities we serve.