Clinical Documentation Specialist I
Tenet Healthcare
full-time
Posted on:
Location Type: Hybrid
Location: San Antonio • Texas • 🇺🇸 United States
Visit company websiteJob Level
Junior
About the role
- Improving overall quality and completeness of clinical documentation
- Performing concurrent record reviews on all selected admissions and documenting findings
- Facilitating modifications to clinical documentation to reflect patient severity of illness and risk of mortality
- Ensuring accuracy and completeness of clinical information used for measuring and reporting outcomes
- Maintaining accurate record of review activities to comply with guidelines
- Identifying opportunities for interdepartmental and intradepartmental operational improvements
- Participating in program related meetings and staff education
Requirements
- Graduate of an accredited school of Nursing, AHIMA accredited school, United States or international school of medicine
- Bachelor’s Degree in Health Information Management and/or Nursing or related healthcare Degree (preferred)
- 0-2 years of CDS experience and 2 years of recent acute care experience in a clinical or inpatient coding setting
- 4 or more years of experience in acute care setting (preferred)
- RHIA, RHIT, CCS, CIC, Certified Documentation Specialist (CCDS), OR Certified Documentation Improvement Professional (CDIP), RN, LVN, LPN, MD, DO, PA, NP (required certifications/licensure)
Benefits
- Medical, dental, vision, and life insurance
- 401(k) retirement savings plan with employer match
- Generous paid time off
- Career development and continuing education opportunities
- Health savings accounts, healthcare & dependent flexible spending accounts
- Employee Assistance program, Employee discount program
- Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical documentation improvementrecord reviewsdocumentation accuracyoutcomes measurementoperational improvementsacute care experienceinpatient coding
Soft skills
attention to detailcommunicationcollaborationfacilitationorganizational skills
Certifications
RHIARHITCCSCICCDDSCDIPRNLVNLPNMD