What are the responsibilities and job description for the Clinical Documentation Specialist position at San Antonio Regional Hospital?
Overview
JOB SUMMARY
The Clinical Document Specialist is responsible for ensuring accurate and compliant physician documentation in the electronic medical record. The CDS performs chart reviews, analyze documentation, clinical conditions and treatment required for an accurate representation of severity of illness. The CDS is responsible for identifying the expected Risk of mortality and complexity of care in support of quality patient care and a healthy revenue cycle.
MINIMUM QUALIFICATIONS
Education: Bachelor’s Degree in related field preferred.
Experience: 5 years of recent experience in clinical health care setting. Prior experience in clinical documentation review preferred as well as an understanding of ICD 10 coding requirements.
Knowledge and Skills: Must possess a high level of clinical knowledge regarding the patient population served in order to participate collaboratively with all member of the care team. Works with minimal supervision, must be able to communicate verbally and written to individuals of varying education levels.
License/Certifications: Current CA RN License, Nurse Practitioner, Physician Assistant, MD graduate/educated in UR or foreign country, Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP). CDS certification is encouraged but not required. CCS is preferred but not required. Must obtain a score of at least 70% on CDI Pre Hire assessment.
Equipment: Demonstrated ability to use technology and appropriate software to support in their daily activities.
Physical Requirements: Must be able to perform the essential physical requirements of the job. Must be able to work fully onsite.
PAY RANGE
$47.90 - $71.84
The posted pay range reflects the lowest to highest pay that was available for this position at the time of posting and may be subject to change. Salary offers are determined by candidate’s relevant experience and skills. For per diem positions, a standard rate is used based on market data and not the candidate’s individual experience.
Salary : $48 - $72
