Clinical Documentation Specialist RN

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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.

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

Houston Methodist is an Equal Opportunity Employer.