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CHRISTUS Health Physician Jobs

RN Job In San Antonio, Texas

Clinical Documentation Specialist - Medical Records - PRN

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Company: CHRISTUS Health Profession/Specialty: RN Location: 2827 Babcock Road
San Antonio, Texas 78229
Type of Facility: Hospital
Job Description


The Clinical Documentation Specialist (CDS) 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 are received for the level of services rendered to the patients.

  • Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.
  • Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation.
  • Maintains positive communication with physicians, nursing and all other disciplines involved in the care of the patient.
  • Works closely with HIM Coding staff to assure documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care.
  • Maintains an electronic DRG worksheet to assist coders on identifying all documented diagnosis and procedures.
  • Updates DRG worksheet to reflect any changes to inpatient status/procedure/treatment and confers with the physician to finalize diagnosis.
  • Consistently meets established productivity targets for record review.
  • Designs and implements in collaboration with physician leadership specific tools to support medical record physician documentation.
  • Develops and implements plans for both formal and informal education of physician, nursing, and other clinical staff on clinical documentation opportunities, coding and reimbursement as well as performance improvement methodologies.
  • Assists in collection and organization of data for analysis by appropriate medical and hospital committees.
  • Identifies strategies for sustained work process changes that facilitate complete accurate clinical documentation.
  • Demonstrates competence to perform assigned responsibilities in a manner that meets the population-specific and developmental needs of the members served by the department.
  • Appropriately adapts assigned assessment, treatment, and/or service methods to accommodate the unique physical, psychosocial, cultural, age-specific and other developmental needs of each member served.
  • Takes personal responsibility to ensure compliance with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entities.
  • Performs all duties in a manner that protects the confidentiality of the patient and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties.
  • Performs other duties as assigned.


  • 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.
  • 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.
  • 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.
  • A minimum of 5 years in area of population to be served is required.
  • Three (3) years pervious acute hospital inpatient coding experience required.
  • Case Management / Utilization Management and discharge planning experience preferred.
  • Must possess a good background in medical terminology and anatomy and physiology as the fundamental of medical science.
  • Registered Health Information Management Administrator Technician (RHIT) required
  • Registered Health Information Management Administrator (RHIA) preferred
  • 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.Certified Inpatient Coding Specialist (CCS) required within 12 months of hire
  • Certified Inpatient Coding Specialist (CCS) required within 12 months of hire
  • CDS certification preferred

Work Type:

Per Diem As Needed

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Job Map - 2827 Babcock Road San Antonio, Texas 78229 United States
CHRISTUS Health Physician Jobs
About CHRISTUS Health

CHRISTUS Health is an international Catholic, faith-based, not-for-profit health system comprised of more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures.

Sponsored by the Sisters of Charity of the Incarnate Word in Houston and San Antonio and the Sisters of the Holy Family of Nazareth, the mission of CHRISTUS Health is to extend the healing ministry of Jesus Christ.

To support our healthcare ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on staff who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.


We are inspired by our mission, vision and core values to deliver compassionate, high quality health care, improving the health of the communities we serve. Above all, we are committed to providing our customers and their family members with a truly unique healing experience, one that embodies our values and respects the dignity and worth of each person. Creating a health care system that is truly excellent in all areas is an ongoing effort.

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