Houston Methodist
Clinical Documentation Specialist - RN Residents of: TX, Louisiana , FL, GA, TN,
Houston Methodist, Granite Heights, Wisconsin, United States
Clinical Documentation Specialist — RN Residents
Houston Methodist is seeking a Clinical Documentation Specialist to enhance the quality and completeness of clinical documentation across our facilities in Texas, Louisiana, Florida, Georgia, Tennessee, and Washington.
Key Responsibilities Analyze medical records for DRGs, complications, and comorbidities; identify trends and recommend documentation improvements. Facilitate modifications to documentation through interaction with physicians, nursing staff, other patient care givers, and coding staff to ensure appropriate reimbursement. Support the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Educate all members of the patient care team on documentation practices on an ongoing basis.
Essential Functions by Domain People — Improve overall quality, completeness, and accuracy of clinical documentation by performing open record reviews using clinical documentation guidelines. Service — Seek additional information regarding clinical condition from appropriate personnel; track responses and trends in completion of DRG/Documentation worksheets. Quality/Safety — Request clarification or correction from physicians for unclear diagnoses, complications, procedures, and clinical information; help identify appropriate ICD10 codes. Finance — Promote clarification to ensure appropriate reimbursement; identify diagnoses and procedures performed and comorbidities and complications; update the DRG worksheet to reflect status changes. Growth/Innovation — Educate internal customers on clinical documentation opportunities, coding, and reimbursement issues and performance improvement methodologies.
Qualifications Education: Medical School graduate practicing western medicine. Experience: One year of clinical experience preferred. Licensure/Certification: Required – CCDS (ACDIS) or CDIP (AHIMA) or CCS (AHIMA).
Skills and Abilities Demonstrated ability to safely perform assigned job responsibilities. Proficient in English (speaking, reading, writing) with focus on patient or employee safety. Effective communication with patients, physicians, family members, and co‑workers. Knowledge of DRG payer issues, documentation requirements, and referral policies. Excellent observation, analytical thinking, problem solving, and verbal/written communication. Assertiveness with a pleasant personality while communicating with others.
Supplemental Requirements Dress: Business professional. On‑call: No. Travel: None within or outside Houston Metropolitan area.
FLSA Status Exempt.
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Key Responsibilities Analyze medical records for DRGs, complications, and comorbidities; identify trends and recommend documentation improvements. Facilitate modifications to documentation through interaction with physicians, nursing staff, other patient care givers, and coding staff to ensure appropriate reimbursement. Support the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Educate all members of the patient care team on documentation practices on an ongoing basis.
Essential Functions by Domain People — Improve overall quality, completeness, and accuracy of clinical documentation by performing open record reviews using clinical documentation guidelines. Service — Seek additional information regarding clinical condition from appropriate personnel; track responses and trends in completion of DRG/Documentation worksheets. Quality/Safety — Request clarification or correction from physicians for unclear diagnoses, complications, procedures, and clinical information; help identify appropriate ICD10 codes. Finance — Promote clarification to ensure appropriate reimbursement; identify diagnoses and procedures performed and comorbidities and complications; update the DRG worksheet to reflect status changes. Growth/Innovation — Educate internal customers on clinical documentation opportunities, coding, and reimbursement issues and performance improvement methodologies.
Qualifications Education: Medical School graduate practicing western medicine. Experience: One year of clinical experience preferred. Licensure/Certification: Required – CCDS (ACDIS) or CDIP (AHIMA) or CCS (AHIMA).
Skills and Abilities Demonstrated ability to safely perform assigned job responsibilities. Proficient in English (speaking, reading, writing) with focus on patient or employee safety. Effective communication with patients, physicians, family members, and co‑workers. Knowledge of DRG payer issues, documentation requirements, and referral policies. Excellent observation, analytical thinking, problem solving, and verbal/written communication. Assertiveness with a pleasant personality while communicating with others.
Supplemental Requirements Dress: Business professional. On‑call: No. Travel: None within or outside Houston Metropolitan area.
FLSA Status Exempt.
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