JPS Health Network · 18 hours ago
Clinical Document Specialist
Fort Worth, TX
Full-time
Onsite
Entry, Mid Level
2+ years expJPS Health Network is a tax-supported healthcare system in North Texas, employing over 7,200 people. The Clinical Documentation Specialist is responsible for reviewing medical records to ensure accurate representation of patient illness through documentation, involving extensive interaction with healthcare providers and staff.
Health Care
Responsibilities
Identify new patient admissions and initiate review of documentation in the medical record utilizing clinical documentation software. Review documentation daily or at an interval appropriate to that patient’s clinical picture
Establish working Diagnosis – Related Group (DRG) based on assignment of International Classification of Disease (ICD) diagnosis and procedure codes
Identify opportunities to impact case mix through documentation of complicating and comorbid, or major complicating and comorbid conditions and formulate a provider query based on query guidelines with timely provider follow-up
Complete provider clarification queries per guidelines for instances in which documentation in the medical record is ambiguous, incomplete or conflicting and provide timely provider follow-up, as needed
Attend medical staff department meetings and present current clinical documentation trends, findings and provide education on the impacts of clinical documentation
Initiate Task Force meetings with the coding staff to discuss DRG assignment discrepancies and create participatory educational sessions regarding clinical conditions, documentation and coding
Performs other related job duties as assigned
Qualification
Required
Associate's Degree in Nursing, Health Information Technology or a related field of study from an accredited college or university
2 plus years of relevant work experience in a hospital setting
High School Diploma
2 plus years of relevant work experience in a hospital setting
Minimum 2 years of experience in CDI or a related field
If applicable team members in this job that hold a professional licensure or credentialed must keep licensure and credentials current
Preferred
Bachelor's Degree in Nursing, Health Information Technology or a related field of study from an accredited college or university
3 years of acute care clinical experience in a critical care or telemetry unit
Current Clinical Documentation Specialist certification through the Association of Clinical Documentation Improvement Specialists (ACDIS) and /or Clinical documentation Improvement Practitioner through the American Health Information Management Association (AHIMA)
Current Medical Coding through AAPC, American Health Information Management Association (AHIMA) and/ or through an organization accredited by the National Commission for Certifying Agencies (NCAA) for Medical Coding
Company
JPS Health Network
The Tarrant County Hospital District, known as JPS Health Network, is a nationally recognized system anchored by John Peter Smith Hospital, a 582-bed facility in Fort Worth.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Stanley C. Adams, MBA
Interim CFO
Colin Werenka
Senior Vice President, Chief Compliance Officer
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