Clinical Documentation Specialist- Denton

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Arlington, TX US
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Full Time
Texas Health Resources System Services

Healthcare System that is ranked #1 as Fortune’s 2015, 2016 and 2017 “Best Workplaces in Health Care" where Helping Hands and Caring Hearts makes a difference!

At Texas Health we are dedicated to finding people to help us fulfill our commitment to make health care human again. We staff our exemplary hospital with health care professionals who approach every patient, every colleague, every physician and every family member with compassion. Come join us on our Journey as we rise to the next level!

Texas Health Denton 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.

1st shift, 40 hours

Location: Texas Health Denton

Required Minimum Education:
ADN required (with RN license) (BSN Preferred);
or Bachelor's Degree in Health Information Management (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 Licenses/Certifications:
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:
The CDS is responsible for concurrently analyzing medical records to facilitate improvement in the overall quality and completeness of the medical record to ensure accurate depiction of the level of clinical services provided and to completely describe the patient’s severity of illness.  This involves extensive record review, interaction with physicians, HIM professionals, and nursing staff.   Active participation in team meetings and ongoing education of staff in the CDMP® (Compliant Documentation Management Program) process is a key role.

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.

Accurate input of data into CDMP Trak:
Using TRAK guidelines after reconciling the coding summary two to three times per week. Ensuring TRAK is up to
date before monthly reports are due.

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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