Clinical Documentation Specialist

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Req #: 8054
Division: Quality
Employment Type: Full Time
Shift: Day
Hours: Mon-Fri 8A-5P
Compensation Type: Salaried
Facility: John Peter Smith Hospital
Location: 1500 S. Main Street, Fort Worth, TX


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:

  1. 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.
  2. Establish working Diagnosis – Related Group (DRG) based on assignment of International Classification of Disease (ICD) diagnosis and procedure codes.
  3. 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.
  4. 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.
  5. Attend medical staff department meetings and present current clinical documentation trends, findings and provide education on the impacts of clinical documentation.
  6. Initiate Task Force meetings with the coding staff to discuss DRG assignment discrepancies and create participatory educational sessions regarding clinical conditions, documentation and coding.
  7. Performs other related job duties as assigned.



    Required Education and Experience:

  • Associate 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.
  • 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.


JPS Health Network is a $950 million, tax-supported health care system for Tarrant County in North Texas. Licensed for 578 beds, the network includes an acute care hospital and more than 40 community-based clinics, including 19 school-based clinics. John Peter Smith Hospital is home to Tarrant County’s first and only Level 1 Trauma Center, its only psychiatric emergency services site and has the largest hospital-based family medicine residency program in the nation. Our network employs more than 6,500 people.

Acclaim is our multispecialty medical practice group. Acclaim has over 300 providers serving the JPS Health Network in specialties ranging from primary care to general surgery and trauma. The Acclaim group has been 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.

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