Clinical Documentation Specialist RNHouston Methodist • Los Angeles, CA, United States
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Clinical Documentation Specialist RN
Houston Methodist • Los Angeles, CA, United States
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job_description.job_card.job_descriptionSeeks 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. 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 Associate's or bachelor's 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 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. 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 Travel specifications may vary by department May require travel within the Houston Metropolitan area No May require travel outside Houston Metropolitan area No
Come lead with us at Corporate
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
Quality / Safety Essential Functions
Finance Essential Functions
Growth / Innovation Essential Functions
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
Work Experience
Licenses And Certifications - Required
Licenses And Certifications - Preferred
KNOWLEDGE, SKILLS, AND ABILITIES
Supplemental Requirements
WORK ATTIRE
ON-CALL
TRAVEL
Houston Methodist is an Equal Opportunity Employer.
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