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Clinical Documentation Specialist

Job Ref: 27377

Talent Area: RN - Other

Houston Methodist San Jacinto Hospital
Baytown, TX 77521

Area/Department: Medical Records

Employment Type: Regular

Job Type: Full-Time

Organization: Houston Methodist

Work Shift: DAY

Work Week: M - F

Company Profile

Houston Methodist San Jacinto Hospital, located 35 miles southeast of Houston, is the area's only full-service hospital offering specialized medical care for patients at every stage in life. This 392 licensed bed hospital with 18 operating rooms, and over 1,400 employees, brings Medical Center excellence and quality care close to East Harris and surrounding counties.

Job Summary


The Clinical Documentation Specialist is 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.



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 payer 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, and 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.  



Graduate of accredited school of professional nursing.  

 Bachelor of Science of Nursing (BSN) preferred.  



At least 5 years recent clinical experience in an acute care hospital setting.   

Utilization review, reimbursement, or coding experience is preferred



Registered Nurse with current Texas licensure



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.