Clinical Documentation Specialist - RN

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.

Exempt

• 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

• 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.

• Work Attire:
  Business professional
• On‑Call:
  No
• Travel:
  No travel within or outside Houston Metropolitan area

• Seniority Level: Entry level
• Employment Type:
  
  Full‑time
• Job Function:
  Health Care Provider
• Industry: Hospitals and Health Care

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