Clinical Documentation Specialist

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Fort Worth, TX US
Job ID:
Area of Interest:
Job Type:
Full Time
Texas Health Fort Worth

Texas Health Fort Worth is seeking a full time Clinical Documentation Specialist who is detail oriented, with exceptional critical thinking skills and the ability to prioritize and analyze data quickly and accurately.

Shift - 1st shift, Monday - Friday
40 hours

Required Minimum Education:
ADN required with RN license; (BSN Preferred)
Bachelor's degree in HIM with RHIT, RHIA, CCS, CCSP certifications

Required Minimum Experience:
2 years clinical experience (ICU/Critical Care Med/Surg Specialty preferred) OR
2 years inpatient coding experience

Required License/Certification:
Current Registered Nurse License eligible to work in the State of Texas; or RHIT, RHIA, CCS, CCS-P if not ADN/BSN.

Prior management, supervisory, leadership experience. Organizational, analytical, writing and interpersonal skills. Knowledge of reimbursement systems, Medicare, Federal, State, and Local payer rules and regulations preferred.

Should also be comfortable teaching in group setting as a large part of the job is educating healthcare providers about current documentation standards and helping them appreciate their role in documentation improvement.

Job Duties:
Accurate and timely record review:
By enrolling available new inpatients every day except weekends and holidays and re-reviews every two days until the patients are discharged.

Recognize opportunities for documentation improvement:
By using strong critical thinking skills, and medical knowledge of disease processes with an exceptional ability to integrate knowledge. Ability to analyze complex clinical information to identify areas within the medical record for potential gaps in physician documentation. Identifies opportunities to justify the intensity of service and severity of
illness and shares this information in an interdisciplinary approach with physicians and staff with the goal of obtaining documentation excellence supporting the care provided to the patient.

Formulate clinically credible and compliant documentation clarifications:
By utilizing the compliant clarification format and clinically credible indicators, sign/symptoms, risk factors, and treatment. Responsible for developing appropriate physician clarification tools and processes in accordance with Medicare and AHIMA.

Effective and appropriate communication with physicians:
By providing necessary feedback and clinically credible clarifications with the ability to strongly communicate clearly, proactively, and concisely when interacting with physicians. Provide education to physicians and other clinical providers to ensure their understanding of the clarification process and the desired outcome of documentation excellence for severity of illness and intensity of care.

Timely follow up on all cases especially those with clinical documentation clarifications:
By reviewing cases with clarifications daily and obtain a documented answer for the clarifications before the patient is discharged. Follows up on all other patients every other day until discharge. Ability to prioritize work flow, keen ability to multi-task, proactively prioritizes initiatives and effectively manages resources.

Entity Information:
Texas Health Resources is one of the largest faith-based, nonprofit health care delivery systems in the United States and the largest in North Texas in terms of patients served.
Texas Health has 25 acute-care and short-stay hospitals that are owned, operated, joint-ventured or affiliated with the system. It has more than 3,800 licensed beds, more than 21,100 employees of fully-owned/operated facilities plus 1,400 employees of consolidated joint ventures, and counts more than 5,500 physicians with active staff privileges at its hospitals.
At Texas Health, we strive to create an atmosphere of respect, integrity, compassion and excellence for all who come in contact with us, be they patients or our employees. We are committed to diversity in our workforce, and our mission to serve spreads across ethnic, cultural, economic and generational boundaries. We invite you to join us in furthering your career through our accomplishments and philosophy of excellence.
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-Employment opportunities are only reflective of wholly owned Texas Health Resources entities.

We are an Equal Opportunity Employer and do not discriminate against any employees or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. LEARN MORE

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