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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 & Certifications (Required):
CCDS - Clinical Documentation Specialists (ACDIS).
Licenses & Certifications (Preferred):
CDIP - Certified Documentation Integrity Practitioner (AHIMA); CCS - Certified Coding Specialist (AHIMA).
Skills and Abilities
Demonstrates the skills and competencies necessary to safely perform the assigned job.
Proficient in speaking, reading, and writing English.
Effective communication with patients, physicians, family members and co-workers.
Knowledge of DRG payer issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures.
Accountability and professional development.
Excellent observation, analytical thinking, problem solving, and communication skills.
Regular significant contacts with other personnel throughout the institution.
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.
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 payer 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 ICD-10 codes for diagnoses or procedures related to projects or studies.
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, 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, reimbursement issues, and 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 (e.g., Disaster, Severe Weather Events) 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
Job code: EX-10801462
Job type: Full-time
Location: Texas
Entry level: 0-2 years
About the company: Houston Methodist
#J-18808-Ljbffr
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 & Certifications (Required):
CCDS - Clinical Documentation Specialists (ACDIS).
Licenses & Certifications (Preferred):
CDIP - Certified Documentation Integrity Practitioner (AHIMA); CCS - Certified Coding Specialist (AHIMA).
Skills and Abilities
Demonstrates the skills and competencies necessary to safely perform the assigned job.
Proficient in speaking, reading, and writing English.
Effective communication with patients, physicians, family members and co-workers.
Knowledge of DRG payer issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures.
Accountability and professional development.
Excellent observation, analytical thinking, problem solving, and communication skills.
Regular significant contacts with other personnel throughout the institution.
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.
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 payer 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 ICD-10 codes for diagnoses or procedures related to projects or studies.
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, 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, reimbursement issues, and 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 (e.g., Disaster, Severe Weather Events) 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
Job code: EX-10801462
Job type: Full-time
Location: Texas
Entry level: 0-2 years
About the company: Houston Methodist
#J-18808-Ljbffr