Job Description
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.
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
This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.
EDUCATION
Associate's or bachelor's degree in nursing
WORK EXPERIENCE
Five years of recent clinical experience caring for adults in an acute care hospital setting
Coding and utilization review experience preferred
LICENSES AND CERTIFICATIONS - REQUIRED
RN - Registered Nurse - Texas State Licensure - Compact Licensure - Must obtain permanent Texas license within 60 days (if establishing Texas residency)
LICENSES AND CERTIFICATIONS - PREFERRED
CCDS - Clinical Documentation Specialists (ACDIS) OR
CDIP - Certified Documentation Integrity Practitioner (AHIMA) OR
CCS - Certified Coding Specialist (AHIMA)
KNOWLEDGE, 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.
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
Company Profile:
Houston Methodist is one of the nation’s leading health systems and academic medical centers. Houston Methodist consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the heart of the Texas Medical Center, and seven community hospitals throughout the greater Houston area. Houston Methodist also includes an academic institute, a comprehensive residency program, a global business division, numerous physician practices and several free-standing emergency rooms and outpatient facilities. Overall, Houston Methodist employs more than 27,000 employees and is supported by a wide variety of business functions that operate at the system level to help enable clinical departments to provide high quality patient care.
Houston Methodist is an Equal Opportunity Employer.
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
This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.
EDUCATION
Associate's or bachelor's degree in nursing
WORK EXPERIENCE
Five years of recent clinical experience caring for adults in an acute care hospital setting
Coding and utilization review experience preferred
LICENSES AND CERTIFICATIONS - REQUIRED
RN - Registered Nurse - Texas State Licensure - Compact Licensure - Must obtain permanent Texas license within 60 days (if establishing Texas residency)
LICENSES AND CERTIFICATIONS - PREFERRED
CCDS - Clinical Documentation Specialists (ACDIS) OR
CDIP - Certified Documentation Integrity Practitioner (AHIMA) OR
CCS - Certified Coding Specialist (AHIMA)
KNOWLEDGE, 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.
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
Company Profile:
Houston Methodist is one of the nation’s leading health systems and academic medical centers. Houston Methodist consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the heart of the Texas Medical Center, and seven community hospitals throughout the greater Houston area. Houston Methodist also includes an academic institute, a comprehensive residency program, a global business division, numerous physician practices and several free-standing emergency rooms and outpatient facilities. Overall, Houston Methodist employs more than 27,000 employees and is supported by a wide variety of business functions that operate at the system level to help enable clinical departments to provide high quality patient care.
Houston Methodist is an Equal Opportunity Employer.
💡 Quick Summary
Seeking a career-building opportunity? The Clinical Documentation Specialist RN position is now open for candidates interested in the Nurse / Compounder Jobs sector. This role in India offers a professional environment and growth potential.
Requirement Snapshot: Candidates should possess basic communication skills, a proactive attitude, and the ability to work in a team. Experience in Nurse / Compounder Jobs is a plus.
