Clinical Documentation Specialist
Job Ref # 31691
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Location: Houston, TX
Category: RN - Performance Improvement/Quality

Work Shift: DAY

Work Week: M - F


Job Summary

03/2017
JOB 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.

PATIENT AGE GROUP(S) AND POPULATION(S) SERVED
Refer to departmental ¿Scope of Service¿ and ¿Provision of Care¿ plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity.


HOUSTON METHODIST EXPERIENCE EXPECTATIONS

I.Provide personalized care and service by consistently demonstrating our I CARE 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. 

II.Focuses on patient/customer safety
III.Delivers personalized service using HM Service Standards
IV.Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)
V.Intentionally rounds with patients/customers to ensure their needs are being met
VI.Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

PRIMARY JOB RESPONSIBILITIES

PEOPLE - 20%
1.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. (EF)

SERVICE - 10%
1.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. (EF)

QUALITY/SAFETY - 30%
1.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. (EF)

FINANCE - 30%
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. (EF)
2.Impacts discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, conferring with physician to finalize diagnosis. (EF)

GROWTH/INNOVATION - 10%
1.Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies. (EF)

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 REQUIREMENTS
Bachelor of Nursing or Medical School Graduate

EXPERIENCE REQUIREMENTS
Registered Nurse - At least five years recent clinical experience caring for adults in an acute care hospital setting. Coding and utilization review experience preferred.
Or
Medical School Graduate - 1 year of clinical experience preferred.


CERTIFICATES, LICENSES AND REGISTRATIONS REQUIRED
Registered Nurse - Current Texas or compact licensure; prefer certification as coding specialist or clinical documentation specialist.
Or
Medical School Graduate ¿ Must have one of the following certifications:  CCS, CCDS or CDIP


KNOWLEDGE, SKILLS AND ABILITIES REQUIRED
¿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.


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

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.

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