Clinical Documentation Specialist - Clinical Documentation

Summary:

The position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement is received for the level of services rendered to the patients.

The Children’s Hospital of San Antonio, established in 1959, was the first children’s hospital in South-Central Texas. Located downtown, this 190-plus-bed hospital serves more than 70,000 children annually from San Antonio, South Texas and around the world. The hospital (in partnership with Baylor College of Medicine) is the only academic children’s hospital in San Antonio. Our highly specialized services meet the unique medical needs of children, from Pediatric and Neonatal Intensive Care to Children’s Emergency Services, the latest treatments for deformities of the spine including titanium rib implants and halo traction, a Heart Center, a specialized asthma program, a highly regarded Cancer and Blood Disorders Center, and growing maternal services to include consultation, delivery, and maternal fetal medicine.

Requirements:

• Registered Health Information Management Administrator (RHIA) or Technician (RHIT) graduate of an approved college program for Health Information Management or graduate of the American Medical Record Associate’s Independent Study Course for Medical Record Technicians is required.
• Certified Inpatient Coding Specialist (CCDS) highly preferred
• If not certified must be eligible to take one of the abovementioned exams and must obtain credentials / certifications within 12 months of hiring date.
• College courses in medical terminology and anatomy and physiology preferred.
• Must be efficient and completely accurate in performance of coding tasks.
• Must be able to accurately read and decipher handwriting that is difficult to read.
• Handwriting of alphabet and numbers must be neat and legible.
• Must be able to work with speed and accuracy and with good eye-hand coordination.
• Must be able to operate computer terminal and other office machines.
• A minimum of 5 years in area of population to be served is required.
  
• Case Management / Utilization Management and discharge planning experience preferred.
• Three (3) years pervious acute hospital inpatient coding experience required.
• Must possess a good background in medical terminology and anatomy and physiology as the fundamental of medical science.
• Must be knowledgeable of the application of the International Classification of Diseases and Operations, Ninth Revision, Clinical Modification, (ICD-9-CM/ICD-10-CM), and Current Procedural Terminology (CPT), Diagnosis Related Groups (DRG) and Ambulatory Payment Classifications (APC).
• Must be familiar with content and arrangement of the medical record.
• Must be familiar with the other functions in Medical Records and how they relate to the Coding function.
• Registered Health Information Management Administrator (RHIA) preferred
  
• Registered Health Information Management Administrator Technician (RHIT) required
• Certified Inpatient Coding Specialist (CCS) required within 12 months of hire
• CDS certification preferred

Work Type:

Part Time