Clinical Documentation Specialist RN

• Associates or bachelors degree in nursing

• Five years of recent clinical experience caring for adults in an acute care hospital setting
• Coding and utilization review experience preferred

• RN - Registered Nurse - Texas State Licensure - Texas Board of NursingPSV Compact Licensure Must obtain permanent Texas license within 60 days (if establishing Texas residency)

• 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
• 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.

• 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.

• 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 patients chart.

• 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.

• 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.

• Educates all internal customers on clinical documentation opportunities coding and reimbursement issues as well as performance improvement methodologies

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

Work Shift:

Job Category:

Houston Methodist is an Equal Opportunity Employer.