Clinical Documentation Specialist
Job Ref # 32037
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Location: Houston, TX
Category: Professional

Work Shift: DAY

Work Week: M - F


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 for the Hospital.  Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians advocating for appropriate demonstration of the intensity of service and severity of illness 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

DUTIES AND RESPONSIBILITIES

Promotes clarification of clinical documentation and documentation thoroughness to ensure that appropriate and accurate coding occurs relevant to the level of services rendered to all patients.

Demonstrates knowledge of DRG assignment and methodology, coding practices and clinical documentation requirements.

Improves overall quality and completeness of clinical documentation by performing concurrent record reviews using clinical documentation guidelines.

Supports the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.

Completes CDMP documentation data base worksheets to include clinical findings relevant to assignment of a working DRG.  Request physician clarification of unclear diagnoses, complications, procedures and clinical documentation.  Updates CDMP worksheets to reflect changes in status, procedures/treatments.  Conducts follow up reviews of clinical documentation to ensure points of clarification have been recorded in the patient record.  Reviews clinical issues with coding staff when necessary to determine working DRG assignment.

Educates internal customers on clinical documentation opportunities, coding, and profiling.

Demonstrates accountability and professional development.  Attends coding clinics, stays updated on coding guidelines.

Demonstrates the components for the I CARE Value Statements (Integrity, Compassion, Accountability, Respect, Excellence) with patients, visitors, physicians and other employees at all times.

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).

Follows all Safety rules.  Reports all accidents and safety hazards promptly; communicates with peers and management regarding any hazards identified in the work place.

Assists with special projects.  Performs other duties as assigned.

EDUCATION REQUIREMENTS

Registered Nurse with current Texas licensure, BSN preferred.

EXPERIENCE REQUIREMENTS

At least five years recent clinical experience in a hospital setting.  Utilization review or coding experience is preferred.

ESSENTIAL TECHNICAL/MOTOR SKILLS

Requires excellent observation skills, analytical thinking, problem solving, and good verbal and written communication and computer skills.  Needs excellent organization/time management, prioritization skills and the ability to multitask.


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.



Company Profile

Houston Methodist West Hospital is committed to leading medicine in West Houston, Katy and surrounding communities by delivering the Houston Methodist standard of exceptional safety, quality, personalized service and innovation. The growing campus offers nearly 200 beds, 16 operating rooms and over 1300 employees, with access to the most innovative medical and surgical care available, including robotic and minimally invasive surgery, full-spectrum heart care, state-of-the-art imaging, cancer care, labor and delivery with a level II neonatal ICU, neurology and neurosurgery, orthopedics and sports medicine, outpatient rehabilitation and 24/7 emergency services. 

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