Clinical Documentation Specialist II
Tenet Healthcare · San Antonio
This position may qualify for a sign-on bonus
- The Clinical Documentation Specialist II 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. Serves as a department educator for other specialists and as a senior team leader in the department. 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. Intermediate level position for experienced CDS. Demonstrates all skills of CDS I with <5% error rate. Completes established competencies for the position within designated introductory period. Other related duties as assigned.
Baptist Health System Hospital is committed to providing exceptional patient care in a supportive and collaborative environment. As a member of our team, you will have the opportunity to work with advanced technology and be part of a healthcare community dedicated to making a positive impact on the lives of our patients.
At Baptist Health System, we understand that our greatest asset is our dedicated team of professionals. That’s why we offer more than a job – we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include:
- 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
Note: Eligibility for benefits may vary by location and is determined by employment status
***Role will be on-site at St. Luke's Baptist Hospital. Medical doctor degrees or foreign graduate doctor degrees are the only acceptable degrees. Along with CCDS or CDIP certificate preferred.***More jobs at Tenet Healthcare · Healthcare & Care jobs in San Antonio