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Lead Clinical Documentation Specialist $2,000 sign-on bonus

Candidates must meet eligibility requirements.

Job Ref: 24250

Talent Area: RN - Other

Houston Methodist St. John Hospital
Nassau Bay, TX 77058

Area/Department: CDI Project

Employment Type: Regular

Job Type: Full-Time

Organization: Houston Methodist

Work Shift: DAY

Work Week: M - F

Company Profile

Houston Methodist St. John Hospital is one of the newest members of the Houston Methodist family—extending its healing mission to the many communities in the Greater Bay Area.  Located on the shores of Clear Lake across from the Johnson Space Center, the facility offers advanced medical and surgical care by team members called to serve with excellence and compassion:

  • 178 beds, 400 physicians and 800 staff members
  • 6 Sports Medicine clinics, 2 Outpatient Laboratory & Imaging clinics


Job Summary

SUMMARY:  Responsible for improving the overall quality and completeness of clinical documentation. Analyzes medical records for DRG`s, complications, and comorbidities. Identifies trends, notes observations and recommendations for documentation improvement. 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. Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes. Educates all members of the patient care team on an ongoing basis.

DUTIES AND RESPONSIBILITIES: 1. 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.  2. 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. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient`s chart.  3. 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.  4. Impacts discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, conferring with physician to finalize diagnosis.  5. Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies.  6. Tracks response to Clinical Documentation Specialist and trends completion of DRG/Documentation worksheets. Provides a weekly report of activities to the CDMP Department at The Methodist Hospital. Reviews with VP of Quality & Care Management the monthly report sent from the CDMP program at TMH.  7. Demonstrates the components of the ICARE values statement (Integrity, Compassion, Accountability, Respect, Excellence).  8. Demonstrates ServicePride standards (smiles and makes eye contact; greets each patient and visitor; seeks out patient and visitor contact; displays appropriate body language at all times; takes 5 minutes each day to go above and beyond for one patient or visitor; honors diversity; thanks every customers).  9. Follows all safety rules while on the job. Reports all accidents promptly and correct minor safety hazards. Communicates with peers and management regarding any hazards identified in the workplace.  10. Performs other duties as assigned. 

EDUCATION REQUIREMENTS:  Graduate of accredited school of professional nursing, Bachelor of Science of Nursing (BSN) preferred Clinical experience in acute care setting

EXPERIENCE REQUIREMENTS:  At least 5  years recent clinical experience in a hospital setting Utilization review, reimbursement, or coding experience is preferred

CERTIFICATES, LICENSES AND REGISTRATIONS REQUIRED:  Registered Nurse with current Texas licensure

CERTIFICATES, LICENSES AND REGISTRATIONS REQUIRED: Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT)WORKING : Normal Office Environment

Equal Employment Opportunity

Houston Methodist is an Equal Opportunity Employer.

Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of  race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law.

VEVRAA Federal Contractor – priority referral Protected Veterans requested.