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Clinical Documentation Specialist

Job Ref: 26518

Talent Area: RN - Performance Improvement/Quality

Houston Methodist Hospital
Houston, TX 77030

Area/Department: Pat Acc Serv-CDMP

Employment Type: Regular

Job Type: Full-Time

Organization: Houston Methodist

Work Shift: DAY

Work Week: M - F

Company Profile

Since its founding in 1919, Houston Methodist Hospital has earned worldwide recognition. Houston Methodist Hospital is affiliated with the Weill Medical College of Cornell University and New York-Presbyterian Hospital, one of the nation's leading centers for medical education and research.  Houston Methodist is consistently ranked in U.S. News & World Report’s “Best Hospital” list and was recently named the number one hospital in Texas. FORTUNE magazine has placed Houston Methodist on its annual list of “100 Best Companies To Work For” since 2006.  Houston Methodist Hospital directs millions of research dollars into patient care and offers the latest innovations in medical, surgical and diagnostic techniques. With 1,119 licensed beds, 67 operating rooms and over 6,000 employees, Houston Methodist offers complete care for patients from around the world.

Job Summary

Responsible for improving the overall quality and completeness of clinical documentation.  Promotes a partnership between the concurrent clinical reviewers, medical record coders, and physicians to improve documentation and reimbursement for the Hospital.  Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians advocating for appropriate reimbursement relative to the patients care, resources consumed and the level of services rendered.  Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patients true severity of illness and intensity of care.  Educates all members of the health care team on an ongoing basis

Select the applicable age group(s) of primary customers/patients served by this position.

¿ Not applicable
¿ Neonate (Birth to 28 days)
¿ Infants/Toddlers (29 days to 18 months)
¿ Toddler (18 months to 3 years)
¿ Preschooler (3-6 years)
¿ School Age (6-12 years)
¿ Adolescence (12-18 years)
¿ Young Adult (19-40 Years)
¿ Middle Adult (40-65 Years)
¿ Mature Adult (65 years and older)

System and department specific ICARE values

INTEGRITY: We are honest and ethical in all we say and do.
COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
ACCOUNTABILITY: We hold ourselves accountable for all our actions.
RESPECT: We treat every individual as a person of worth, dignity, and value.
EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.

Duties and Responsibilities are cross-referenced to the hospital¿s Pillars of Excellence and will be transferred to the Performance Evaluation.

1. Educates all internal customers on clinical documentation opportunities, coding and profiling.
2. Assists with special projects.
3. Demonstrates the components for the I CARE Value Statements (Integrity, Compassion, Accountability, Respect, Excellence) with patients, visitors, physicians and other employees at all times.

1. Promotes clarification of clinical documentation and documentation thoroughness to ensure that appropriate reimbursement is received for the level of services rendered to all patients.
2. Completes CDMP documentation database worksheets to include clinical findings relevant to assignment of a working DRG; updates CDMP worksheets to reflect changes in status, procedures/treatments.
3. Requests physician clarification of unclear diagnoses, complications, procedures and clinical documentation.
4. Conducts follow up reviews of clinical documentation to ensure points of clarification have been recorded in the patient record.
5. Reviews clinical issues with coding staff when necessary to determine working DRG assignment.

1. Demonstrates knowledge of DRG assignment and methodology, coding practices and clinical documentation practices.
2. Improves the overall quality and completeness of clinical documentation by performing concurrent reviews using clinical documentation guidelines.
3. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
4. Follows all safety rules. Reports all accidents and safety hazards promptly; communicates with peers and management regarding any hazards identified in the workplace.

1. Demonstrates Service Pride Standards (Smiles and makes eye contact, greets patients and visitors, displays appropriate body language, takes 5 minutes each day to go above and beyond, honors diversity, thanks every customer).

1. Demonstrates accountability and professional development.
2. Attends coding clinics and stays updated on coding guidelines.
3. Assists with special projects.

This position description is not intended to be all inclusive, and the employee will also perform other reasonably related business duties as assigned by the immediate supervisor and other management as required. The Houston Methodist Hospital reserves the right to revise or change job duties and responsibilities as the need arises.

Bachelor of Nursing is required.

At least five years recent clinical experience caring for adults in an acute care hospital setting.
Coding experience is preferred.

Registered Nurse with current Texas licensure.

Requires assertiveness, even temperament, a pleasing personality and the ability to communicate easily with others, both internal and external to the organization, in person, by e-mail, by telephone or through written correspondence.

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.