Houston Methodist
Clinical Documentation Specialist RN (Remote) must live in TX, LA, WA, FL or GA
Houston Methodist, Houston, Texas, United States, 77246
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
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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
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