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Specialist Clinical Documentation II Full Time Days BHS
Job ID: 2503021749-0
Date posted: 08/10/2025
Facility: Baptist Health System
Job Details
Description
This position may qualify for a sign-on bonus.
POSITION SUMMARY
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. Completes established competencies for the position within designated introductory period. Other related duties as assigned.
2503021749Qualifications
MINIMUM EDUCATION: Graduate of an accredited school of Nursing, AHIMA accredited school, United States or International School of Medicine
PREFERRED EDUCATION: Bachelor’s Degree in Health Information Management and/or Nursing or other Healthcare related field.
MINIMUM EXPERIENCE: 2-5 years of CDS experience in acute care setting
PREFERRED EXPERIENCE: 6 or more years of experience in acute care setting
REQUIRED CERTIFICATIONS/LICENSURE: RHIA, RHIT, CCS, Certified Clinical Documentation Specialist (CCDS), OR Certified Documentation Improvement Professional (CDIP), RN, LVN, LPN. MD, DO, PA, NP.
PREFERRED CERTIFICATIONS/LICENSURE: NA
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