Clinical Documentation Specialist - RN
Houston Methodist, Houston, Texas, United States, 77246
Clinical Documentation Specialist - RN Resident
Location:
Texas, Louisiana, Florida, Georgia, Tennessee, Washington
Company:
Houston Methodist
Join us as a Clinical Documentation Specialist responsible for improving the overall quality and completeness of clinical documentation. This role analyzes medical records for DRG, complications, and co‑morbidities; identifies trends; recommends documentation improvements; and facilitates modifications through extensive interaction with physicians, nursing staff, other patient‑care givers, and coding staff to ensure appropriate reimbursement.
Additional duties include supporting the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes and educating all members of the patient care team on an ongoing basis.
FLSA Status Exempt
Qualifications
Education:
Medical School graduate where Western Medicine is practiced
Experience:
One year of clinical experience preferred
Licenses & Certifications:
CCDS – Clinical Documentation Specialist (ACDIS)
CDIP – Certified Documentation Integrity Practitioner (AHIMA)
CCS – Certified Coding Specialist (AHIMA)
Skills & Abilities:
Demonstrates required skills and competencies, assessed through ongoing evaluations
Proficiency in speaking, reading, and writing English for patient or employee safety
Effective communication with patients, physicians, families, and co‑workers, applying positive language principles
Knowledge of DRG payer issues, appropriate assignment alternatives, documentation requirements, and referral policies
Accountability and professional development
Excellent observation, analytical thinking, problem‑solving, and communication skills
Regular significant contacts with physicians, mid‑level providers, coders, and case managers, requiring assertiveness and calm demeanor
Essential Functions
People Essential Functions:
Improve overall quality, completeness, and accuracy of clinical documentation by performing open record reviews using guidelines and supporting accuracy for reporting outcomes.
Service Essential Functions:
Seek additional information regarding clinical condition from appropriate personnel and follow up as necessary.
Track responses and trends; complete DRG/documentation worksheets.
Conduct follow‑up reviews to confirm clarifications recorded in the chart.
Quality/Safety Essential Functions:
Demonstrate knowledge of DRG payer issues, optimization strategies, documentation requirements, and referral policies.
Request clarification or correction from physicians for unclear diagnoses, complications, procedures, and clinical information.
Assist in identifying appropriate ICD‑10 codes for projects or studies.
Finance Essential Functions:
Promote clarification to ensure appropriate reimbursement.
Identify diagnoses, procedures, comorbidities and complications.
Update DRG worksheet to reflect any status changes and coordinate with physicians to finalize diagnoses.
Growth/Innovation Essential Functions:
Educate internal customers on documentation opportunities, coding, reimbursement, and performance improvement methodologies.
Supplemental Requirements
Work Attire: Business professional
On‑Call: No
Travel: No travel within or outside Houston Metropolitan area
Employment Details
Seniority Level: Entry level
Employment Type: Full‑time
Job Function: Health Care Provider
Industry: Hospitals and Health Care
Referrals increase your chances of interviewing at Houston Methodist by 2x.
#J-18808-Ljbffr
Texas, Louisiana, Florida, Georgia, Tennessee, Washington
Company:
Houston Methodist
Join us as a Clinical Documentation Specialist responsible for improving the overall quality and completeness of clinical documentation. This role analyzes medical records for DRG, complications, and co‑morbidities; identifies trends; recommends documentation improvements; and facilitates modifications through extensive interaction with physicians, nursing staff, other patient‑care givers, and coding staff to ensure appropriate reimbursement.
Additional duties include supporting the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes and educating all members of the patient care team on an ongoing basis.
FLSA Status Exempt
Qualifications
Education:
Medical School graduate where Western Medicine is practiced
Experience:
One year of clinical experience preferred
Licenses & Certifications:
CCDS – Clinical Documentation Specialist (ACDIS)
CDIP – Certified Documentation Integrity Practitioner (AHIMA)
CCS – Certified Coding Specialist (AHIMA)
Skills & Abilities:
Demonstrates required skills and competencies, assessed through ongoing evaluations
Proficiency in speaking, reading, and writing English for patient or employee safety
Effective communication with patients, physicians, families, and co‑workers, applying positive language principles
Knowledge of DRG payer issues, appropriate assignment alternatives, documentation requirements, and referral policies
Accountability and professional development
Excellent observation, analytical thinking, problem‑solving, and communication skills
Regular significant contacts with physicians, mid‑level providers, coders, and case managers, requiring assertiveness and calm demeanor
Essential Functions
People Essential Functions:
Improve overall quality, completeness, and accuracy of clinical documentation by performing open record reviews using guidelines and supporting accuracy for reporting outcomes.
Service Essential Functions:
Seek additional information regarding clinical condition from appropriate personnel and follow up as necessary.
Track responses and trends; complete DRG/documentation worksheets.
Conduct follow‑up reviews to confirm clarifications recorded in the chart.
Quality/Safety Essential Functions:
Demonstrate knowledge of DRG payer issues, optimization strategies, documentation requirements, and referral policies.
Request clarification or correction from physicians for unclear diagnoses, complications, procedures, and clinical information.
Assist in identifying appropriate ICD‑10 codes for projects or studies.
Finance Essential Functions:
Promote clarification to ensure appropriate reimbursement.
Identify diagnoses, procedures, comorbidities and complications.
Update DRG worksheet to reflect any status changes and coordinate with physicians to finalize diagnoses.
Growth/Innovation Essential Functions:
Educate internal customers on documentation opportunities, coding, reimbursement, and performance improvement methodologies.
Supplemental Requirements
Work Attire: Business professional
On‑Call: No
Travel: No travel within or outside Houston Metropolitan area
Employment Details
Seniority Level: Entry level
Employment Type: Full‑time
Job Function: Health Care Provider
Industry: Hospitals and Health Care
Referrals increase your chances of interviewing at Houston Methodist by 2x.
#J-18808-Ljbffr