Clinical Documentation Specialist - RN

Overview

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 DRGs, complications, and comorbidities; identifies trends; and notes observations and recommendations for documentation improvement. This role 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.

• 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)

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
• Proficiency in speaking, reading, and writing English to perform essential functions, especially with regard to activities impacting patient or employee safety or security
• Ability to effectively communicate with patients, physicians, family members and co-workers with a customer service focus
• Knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies
• Accountability and professional development
• Excellent observation, analytical thinking, problem solving, and verbal and written communication
• Regular significant contacts with physicians, staff, coders, Case Managers, and others; assertiveness with even temper and positive communication

• People Essential Functions - Improves the overall quality, completeness and accuracy of clinical documentation by performing open record reviews and supporting information used for measuring and reporting physician and medical outcomes
• Service Essential Functions - Seeks additional information regarding clinical condition and follows up; tracks responses and trends related to DRG/Documentation worksheets
• Quality/Safety Essential Functions - Identifies DRG payor issues, clarification with physicians for unclear diagnoses, and helps identify appropriate ICD-10 codes for projects
• Finance Essential Functions - Promotes clarification to ensure appropriate reimbursement; updates DRG worksheet to reflect changes, in consultation with physicians
• Growth/Innovation Essential Functions - Educates internal customers on clinical documentation opportunities, coding, and reimbursement issues

• Work Attire - Uniform:
  No;
  Scrubs:
  No;
  Business professional:
  Yes;
  Other:
  No
• On-Call
  - Note:
  
  employees may be required to be on-call during emergencies;
  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