What are the responsibilities and job description for the Clinical Documentation Specialist RN position at Houston Methodist?
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.
EDUCATION
EXPERIENCE
LICENSES AND CERTIFICATIONS
Required
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
EXPERIENCE
LICENSES AND CERTIFICATIONS
Required
SKILLS AND ABILITIES
ESSENTIAL FUNCTIONS
PEOPLE ESSENTIAL FUNCTIONS
SERVICE ESSENTIAL FUNCTIONS
QUALITY/SAFETY ESSENTIAL FUNCTIONS
FINANCE ESSENTIAL FUNCTIONS
GROWTH/INNOVATION ESSENTIAL FUNCTIONS Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies
SUPPLEMENTAL REQUIREMENTS
QUALIFICATIONSExempt
QUALIFICATIONS
EDUCATION
- Medical School graduate where Western Medicine is practiced
EXPERIENCE
- One year of clinical experience preferred
LICENSES AND CERTIFICATIONS
Required
- 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
- 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
- May require travel within the Houston Metropolitan area No
- May require travel outside Houston Metropolitan area No
ON-CALL*
TRAVEL**
**Travel specifications may vary by department**
EDUCATION
- Medical School graduate where Western Medicine is practiced
EXPERIENCE
- One year of clinical experience preferred
LICENSES AND CERTIFICATIONS
Required
- CCDS - Clinical Documentation Specialists (ACDIS) or
- CDIP - Certified Documentation Integrity Practitioner (AHIMA) or CCS - Certified Coding Specialist (AHIMA)
Company Profile:
Houston Methodist is one of the nation’s leading health systems and academic medical centers. The health system consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the Texas Medical Center, seven community hospitals and one long-term acute care hospital throughout the Greater Houston metropolitan area. Houston Methodist also includes a research institute; a comprehensive residency program; international patient services; freestanding comprehensive care clinics, emergency care and imaging centers; and outpatient facilities. Come lead with us!
Houston Methodist is an Equal Opportunity Employer.