Clinical Documentation Specialist RN

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The candidate for this role must live in these states: TX, LA, WA, FL or GA.
At Houston Methodist, the Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation. This position analyzes medical records for DRG's, complications, and comorbidities; identifies trends; and notes observations and recommendations for documentation improvement. This role also facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients. 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 AND CERTIFICATIONS
Required Preferred

CCDS - Clinical Documentation Specialists (ACDIS) or
CDIP - Certified Documentation Integrity Practitioner (AHIMA) or
CCS - Certified Coding Specialist (AHIMA)
Skills And Abilities

Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures
Demonstrates accountability and professional development
Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
Regular significant contacts with other personnel throughout the institution (including but not limited to – physicians and their staff, mid-level providers, mid-level staff, coders, Case Managers). Contacts may be in person, by telephone, or through correspondence. Requires assertiveness while being even tempered, with a pleasing personality and the ability to communicate easily with others.
Essential Functions
PEOPLE ESSENTIAL FUNCTIONS

Improves the overall quality, completeness and accuracy of clinical documentation by performing open record reviews using clinical documentation guidelines. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical outcomes.
Service Essential Functions

Seeks additional information regarding clinical condition from appropriate clinical personnel and follows up as necessary. Tracks responses and trends completion of DRG/Documentation worksheets as pertinent to scope of department.
Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
Quality/Safety Essential Functions

Demonstrates knowledge of DRG payor issues, optimization strategies, clinical documentation requirements and referral policies and procedures. Requests clarification and/or correction from physicians for unclear diagnoses, complications, procedures, and clinical information. Helps identify appropriate ICD10 codes for diagnoses or procedures related to projects or studies being conducted as needed.
Finance Essential Functions

Promotes clarification to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients. Identifies diagnoses and procedures performed and comorbidities and complications. Impacts discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, conferring with physician to finalize diagnosis as necessary.
Growth/Innovation Essential Functions

Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies
Supplemental Requirements
WORK ATTIRE

Uniform: No
Scrubs: No
Business professional: Yes
Other (department approved): No
ON-CALL*

Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.
On Call* No
TRAVEL**

Travel specifications may vary by department**
May require travel within the Houston Metropolitan area No
May require travel outside Houston Metropolitan area No
Preferred

CCDS - Clinical Documentation Specialists (ACDIS) or
CDIP - Certified Documentation Integrity Practitioner (AHIMA) or
CCS - Certified Coding Specialist (AHIMA)
Houston Methodist is an Equal Opportunity Employer.