Clinical Document Specialist

Who We Are

JPS Health Network is a $950 million, tax‑supported healthcare system in North Texas. Licensed for 582 beds, the network features over 25 locations across Tarrant County, including John Peter Smith Hospital, a Level I Trauma Center, Tarrant County’s only psychiatric emergency center, and the largest hospital‑based family medicine residency program in the nation. The health network employs more than 7,200 people. Acclaim Multispecialty Group is the medical practice group featuring over 300 providers serving JPS Health Network.

Specialties range from primary care to general surgery and trauma. Our goal is to provide high quality, compassionate clinical care for every patient, every time.

We’re more than a hospital. We are 7,200 dedicated people working to provide the care the community deserves. Our core values:

• Own it:
  Everyone wearing the JPS badge contributes to our journey to excellence.
• Seek joy:
  Every day, every shift, we celebrate our patients, smile, and emphasize positivity.
• Don’t be a jerk:
  Everyone is treated with courtesy and respect.

Clinical Document Specialist

43310

Full Time

Health Information Management

Salaried

Nursing / LVN

8:00 AM – 5:00 PM

John Peter Smith Hospital

Day

The Clinical Documentation Specialist (CDS) reviews the medical records of hospitalized patients to ensure accurate representation of severity of illness through provider documentation. This involves extensive record review and interaction with physicians, mid‑levels, residents, nurses, ancillary staff, and coders.

• Identify new patient admissions and initiate review of documentation using clinical documentation software. Review documentation daily or at an interval appropriate to the patient’s clinical picture.
• Establish working Diagnosis‑Related Group (DRG) based on assignment of International Classification of Disease (ICD) diagnosis and procedure codes.
• 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.
• Complete provider clarification queries per guidelines for instances where documentation is ambiguous, incomplete or conflicting, and provide timely provider follow‑up as needed.
• Attend medical staff department meetings and present current clinical documentation trends, findings, and provide education on the impacts of clinical documentation.
• Initiate task force meetings with the coding staff to discuss DRG assignment discrepancies and create participatory educational sessions regarding clinical conditions, documentation, and coding.
• Perform other related job duties as assigned.

• Associate’s Degree in Nursing, Health Information Technology, or a related field from an accredited college or university.
• 2+ years of relevant work experience in a hospital setting.
• OR
• High School Diploma with 2+ years of relevant work experience in a hospital setting.
• Minimum 2 years of experience in CDI or a related field.

• Bachelor’s Degree in Nursing, Health Information Technology, or a related field from an accredited college or university.
• 3 years of acute care clinical experience in a critical care or telemetry unit.

• If applicable, team members in this job holding a professional licensure or credential must keep licensure and credentials current.

• 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 certification through AAPC, AHIMA, or an organization accredited by the National Commission for Certifying Agencies (NCAA) for medical coding.

1500 S. Main Street
Fort Worth, Texas 76104
United States