Clinical Document Specialist

JPS Health Network; Fort Worth (TX); On-site; USD 75,000 - 110,000; Full time

Job summary

JPS Health Network in Fort Worth, TX seeks a Clinical Documentation Specialist to ensure accurate representation of patient illness through provider documentation within hospitalized care teams.

You will review medical records, collaborate with physicians and coding staff, and drive documentation improvements across the organization to support quality outcomes and compliant coding practices.

Qualifications

• Associate’s Degree in Nursing, Health Information Technology or related field.
• 2+ years of hospital CDI experience.
• High School Diploma with 2+ years of CDI experience.

Responsibilities

• Review hospitalized patients' records to accurately represent severity of illness.
• Establish DRG based on ICD diagnosis and procedures.
• Identify opportunities to impact case mix through documentation of comorbid conditions and provider queries.
• Complete provider clarification queries when documentation is ambiguous or incomplete.
• Present clinical documentation trends at medical staff meetings and educate on documentation impact.
• Lead Task Force meetings with coding staff to discuss DRG discrepancies and education.
• Perform other related duties as assigned.

Skills

CDI

Medical coding

Healthcare documentation

Education

Associate’s Degree in Nursing, HIT or related field

High School Diploma with CDI experience

Bachelor’s Degree (preferred)

Tools

Clinical documentation software

ICD coding systems

Job description

Who We AreJPS Health Network is a $950 million, tax-supported healthcare system in North Texas. Licensed for 582 beds, the network features over 25 locations across Tarrant County, with John Peter Smith Hospital a Level I Trauma Center, Tarrant County's only psychiatric emergency center, and the largest hospital-based family medical residency program in the nation. The health network employs more than 7,200 people.

Acclaim Multispecialty Group is the medical practice group featuring over 300 providers serving JPS Health Network. Specialties range from primary care to general surgery and trauma. The Acclaim Multispecialty Group formed around a common set of incentives and expectations supporting the operational, financial, and clinical performance outcomes of the network. Our goal is to provide high quality, compassionate clinical care for every patient, every time.

Why JPS?We're more than a hospital. We're 7,200 of the most dedicated people you could ever meet. Our goal is to make sure the people of our community get the care they need and deserve. As community stewards, we abide by three Rules of the Road:

1. Own it.Everyone who wears the JPS badge contributes to our journey to excellence.
2. Seek joy.Every day, every shift, we celebrate our patients, smile, and emphasize positivity.
3. Don't be a jerk.Everyone is treated with courtesy and respect. Smiling, laughter, compassion - key components of our everyday experience at JPS.

When working here, you're surrounded by passion, diversity, and dedication. We look forward to meeting you!

Description: The Clinical Documentation Specialist (CDS) is responsible for concurrently reviewing the medical records of hospitalized patients to facilitate the accurate and complete representation of severity of patient illness through provider documentation. This involves extensive record review, interaction with physicians, mid - levels, residents, nursing, ancillary staff, and coders.

Typical Duties:

• 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.

Qualifications:

Required Education and Experience:

• 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
• OR
• 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

Preferred Education and Experience:

• 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.

Required Licensure/Certification/Specialized Training:

• If applicable team members in this job that hold a professional licensure or credentialed must keep licensure and credentials current.

Preferred Licensure/Certification/Specialized Training:

• 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.

Location Address:
1500 S. Main Street
Fort Worth, Texas, 76104
United States