Clinical Documentation Specialist Coder

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POST DATE 8/27/2016
END DATE 10/27/2016

Christus Health San Antonio, TX

San Antonio, TX
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Entry Level (0 - 2 years)



This 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 caregivers and health information management coding staff to ensure that reimbursement is received for the level of services rendered to the patients.



A. Education/Skills:

* Credentials Required.
* 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 Association's Independent Study Course for Medical Record Technicians; Cerified Inpatient Coding Specialist ( CCS ).
* If not certified must be eligible to take one of the above mentioned exams, and must obtain credentials / certifications within 12 months of hiring date.
* College courses in medical terminology and anatomy and physiology.
* 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
* Demostrate competence by achieving an accuracy ratio of greater than 96% on hospital coding examination.

B. Experience:

* A minimum of 5 years in clinical practice for population to beserved is required.
* Case Management / Utilization management and discharge planning experience preferred.
* Three (3) years previous acute hospital inpatient coding experience required.
* Must possess a good background in medical terminology and anatomy and physiology as the fundamentals of medical science.
* Must be knowledgeable of the application of the International Classification of Diseases and Operations, Ninth Revision, Clinical Modification, (ICD-9-CM), and Current Procedural Terminology (CPT), Diagnosis Related Groups (DRG) and Ambulatory Payment Classifications (APC).
* Must be familiar with physicians' handwriting.
* Must be familiar with the content and arrangement of the medical record.
* Must be familiar with other functions in Medical Records and how they relate to the Coding function.

C. Licenses, Registrations, or Certifications:

* Registered Health Information Management Technician (RHIT).
* Registered Health Information Management Administrator (RHIA).
* Certified Coding Specialist (CCS).
* CDS certification preferred.
* CPR optional.