Specialist Clinical Documentation I

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. Communicates with the individual physician or medical staff departments to facilitate complete and accurate documentation of the inpatient record Query process. Serves as a resource for physicians to help link ICD-10-CM/PCS coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk of mortality, and final code assignment Works in collaborative fashion with the Coders and Case Managers concurrently reviewing the inpatient medical record to assure correct provisional and final DRG assignment Monitors and evaluates effectiveness of concurrent chart review and query outcomes at designated intervalsReports concurrent chart review and query outcomes to hospital departments and committees at designated intervals Performs monthly closed chart reviews and serves on the Chart Documentation Committee Identifies, assists and participates in intradepartmental and interdepartmental special projects involving accuracy of physician documentation and reporting outcomes Utilizes resources efficiently and effectively Maintains safe environment Participates in Performance Improvement activities This position may qualify for a sign‑on bonus. SUMMARY 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. 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. Completes established competencies for the position within designated introductory period. Other related duties as assigned. MINIMUM EDUCATION: Graduate of an accredited school of Nursing, AHIMA accredited school, United States or international school of medicine. PREFERRED EDUCATION: Bachelor’s Degree in Health Information Management and/or Nursing or related healthcare Degree. MINIMUM EXPERIENCE: 0‑2 years of CDS experience and 2 years of recent acute care experience in a clinical or inpatient coding setting. PREFERRED EXPERIENCE: 4 or more years of experience in acute care setting. REQUIRED CERTIFICATIONS/LICENSURE: RHIA, RHIT, CCS, CIC, Certified Documentation Specialist (CCDS), OR Certified Documentation Improvement Professional (CDIP), RN, LVN, LPN, MD, DO, PA, NP. PREFERRED CERTIFICATIONS/LICENSURE: NA REQUIRED COURSES/COMPLETIONS (e.g., CPR): NA Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship. Tenet participates in the E‑Verify program. Follow the link below for additional information. E‑Verify: The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations. #J-18808-Ljbffr