POSITION SUMMARY

The role of Clinical Documentation Specialist of Clinical Documentation Improvement Department (CDI) works closely with the Director of CDI in addition to the other clinical documentation specialists, medical and coding staff in support of excellence in patient information documented in the medical record. Primary purpose of this role is to provide oversite of the medical record that ensures care, and treatments are documented in support of patient care and accurate DRG assignment. The goal being to accurately define coding and documentation specificity by educating physicians, clinicians, and other interested parties regarding the necessity of providing complete and clear documentation of the care provided. The role of Clinical Documentation Specialist of CDI will ensure the specialists review thorough and proper documentation during the patient's stay. The Clinical Documentation Specialist of CDI will be accountable for the concurrent review of medical records to track documentation supporting the severity of the illness and resources utilized. This position will use existing clinical knowledge from previous training to impart the values of clinical documentation across the various DHR Health departments. This role will require utilize the candidate's previous clinical experience in a hospital setting to leverage knowledge of clinical medicine in regards to the proper documentation needed on a daily basis. The role will require both onsite and off-site completion of daily job requirements. This position may require travel to facilities (Cameron County and Starr County) outside the DHR main campus which is required to oversee operations of clinical documentation in facilities working in partnership with

DHR. QUALIFICATIONS

Foreign Medical graduate (M.D) (APP) Doctor of Osteopathy (D.O). More than 2 years of clinical experience in acute care setting Proficiency in written and spoken English CCS Exam certification or CCDS Exam certification after two years of employment but must be obtained no later than 2 ½ years after hire date. Able to meet the requirements for CCS Exam requirements either based on experience or education as detailed on the AHIMA or the CCDS Exam requirements as detailed on the

ACDIS/AHIMA

website.

JOB KNOWLEDGE/EXPERIENCE

Minimum 1 year clinical experience in acute care setting Knowledge of EMR and related medical record documents, coding and documentation. Knowledge of disease process and pathology amongst various patient populations. Knowledge of treatment modalities for disease process and pathologies. Strong understanding of anatomy, pathology, pharmacology and physiology of disease process. Excellent written, verbal communication skills and critical thinking skills. Able to work with teams and independently.

Job Type:

Full-time Benefits:

401(k) Dental insurance Employee discount Health insurance Life insurance Paid time off Retirement plan Vision insurance

Experience:

Utilization review: 1 year (Preferred)

License/Certification:

RN (Preferred) Ability to

Commute:

Edinburg, TX 78539 (Required) Ability to

Relocate:

Edinburg, TX 78539: Relocate before starting work (Required)

Work Location:

In person