Clinical Documentation Specialist II

Overview

Baptist Health System Hospital is committed to providing exceptional patient care in a supportive and collaborative environment. As a member of our team, you will have the opportunity to work with advanced technology and be part of a healthcare community dedicated to making a positive impact on the lives of our patients.

Baptist Health System has more than 120 years history of caring for our community and making a positive difference. Our system of care includes six full-service hospitals, a specialized childrens hospital with a dedicated pediatric emergency unit, a comprehensive cancer care network, fitness and rehabilitation centers, a physician network, imaging centers, ambulatory services and the Baptist School of Health Professions. Wherever you go in the Baptist Health System, youll find that we have the same goal to help people achieve health for life through compassionate service inspired by faith.

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

Eligibility for benefits may vary by location and is determined by employment status.

The Clinical Documentation Specialist II is responsible for improving overall quality and completeness of clinical documentation. Performs concurrent record reviews on all selected admissions and documents findings. Facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management, nursing staff, other patient care givers and health information management coding staff.

Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Maintains accurate record of review activities to comply with departmental and regulatory agency guidelines. Understands and complies with policies and procedures related to confidentiality of medical records. Serves as a department educator for other specialists and as a senior team leader in the department.

Identifies opportunities for interdepartmental and intradepartmental operational improvements. Participates in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities. Intermediate level position for experienced CDS. Demonstrates all skills of CDS I with