Clinical Documentation Specialist
CHRISTUS Santa Rosa
CHRISTUS Santa Rosa Medical Ct-30300
2827 Babcock Road
San Antonio, TX 78229
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The 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 care givers and health information management coding staff to ensure that reimbursement is received for the level of services rendered to the patients.
- 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.
- Certified Inpatient Coding Specialist (CCS) highly preferred
- If not certified must be eligible to take one of the above mention exams, and must obtain credentials / certifications within 12 months of hiring date.
- 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 which 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 demonstrate competency by achieving an accuracy rating of greater than 96% on hospital coding examination. To provide documentation of this to their manager/director.
- A minimum of 5 years in area of population to be served is required.
- Case Management / Utilization Management and discharge planning experience preferred.
- Three (3) years pervious acute hospital inpatient coding experience required.
- Must possess a good background in medical terminology and anatomy and physiology as the fundamental of medical science.
- 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.
C. Licenses, Registrations, or Certifications
- Registered Health Information Management Administrator (RHIA) preferred
- Registered Health Information Management Administrator Technician (RHIT) required
- Certified Inpatient Coding Specialist (CCS) required within 12 months of hire
- CDS certification preferred