CLIN DOCUMENTATION SPEC I

Methodist Health System • Dallas, TX

55d • Remote

About The Position

Your Job: The Clinical Documentation Specialist is responsible for reviewing medical records concurrently to facilitate accurate representation of severity of illness by improving the quality of the physicians' clinical documentation. This involves extensive record analysis, interaction with physicians, HIM professionals, and nursing staff. Supports the mission, vision, values and strategic goals of Methodist Health System. Fully remote position. Your Job Requirements: Graduate from an accredited school of nursing. Bachelor degree preferred. RN - required; CCDS, CDIP, CCS - preferred Basic computer skills Critical thinking/problem-solving skills Organizational, analytical, writing and interpersonal skills Work Experience: 2 years of recent hospital experience required, preferably ICU, CCU or strong med/Surg. CDI, coding or utilization review experience is a plus. Your Job Responsibilities: Successfully managing multiple priorities: query follow-up, initial chart review, concurrent chart review, MS-DRG discrepancy resolution. Efficient knowledge and usage of tools provided for position including computer software. Accurate input of data into the computerized system. Effective and appropriate communication with physicians and hospital staff. Perform thorough initial and concurrent medical chart reviews identifying opportunities for documentation improvement. Verify that all treated or monitored conditions are properly documented by the physician in the medical record using specific ICD-10 diagnostic terms. Verify that all documented diagnoses are clinically supported using industry-accepted diagnostic criteria. Formulate clinically credible, compliant queries for the medical staff to ensure accurate and complete documentation. Complete timely follow up on all cases; especially those with physician queries (every 1-2 days). Communicate with HIM coding staff to resolve MSDRG discrepancies. Utilize monitoring tools to track progress of the CDI program. Methodist Health System is a faith-based organization with a mission to improve and save lives through compassionate, quality healthcare. For nearly a century, Dallas-based Methodist Health System has been a trusted choice for health and wellness. Named one of the fastest-growing health systems in America by Modern Healthcare, Methodist has a network of 12 hospitals (through ownership and affiliation) with nationally recognized medical services, such as a Level I Trauma Center, multi-organ transplantation, Level III Neonatal Intensive Care, neurosurgery, robotic surgical programs, oncology, gastroenterology, and orthopedics, among others. Methodist has more than two dozen clinics located throughout the region, renowned teaching programs, innovative research, and a strong commitment to the community. Our reputation as an award-winning employer shows in the distinctions we've earned: TIME magazine Best Companies for Future Leaders, 2025 Great Place to Work Certified, 2025 Glassdoor Best Places to Work, 2025 PressGaney HX Pinnacle of Excellence Award, 2024 PressGaney HX Guardian of Excellence Award, 2024 PressGaney HX Health System of the Year, 2024

Requirements

• Graduate from an accredited school of nursing.
• RN - required
• Basic computer skills
• Critical thinking/problem-solving skills
• Organizational, analytical, writing and interpersonal skills
• Work Experience: 2 years of recent hospital experience required, preferably ICU, CCU or strong med/Surg.

Nice To Haves

• Bachelor degree preferred.
• CCDS, CDIP, CCS - preferred
• CDI, coding or utilization review experience is a plus.

Responsibilities

• Successfully managing multiple priorities: query follow-up, initial chart review, concurrent chart review, MS-DRG discrepancy resolution.
• Efficient knowledge and usage of tools provided for position including computer software. Accurate input of data into the computerized system.
• Effective and appropriate communication with physicians and hospital staff.
• Perform thorough initial and concurrent medical chart reviews identifying opportunities for documentation improvement.
• Verify that all treated or monitored conditions are properly documented by the physician in the medical record using specific ICD-10 diagnostic terms.
• Verify that all documented diagnoses are clinically supported using industry-accepted diagnostic criteria.
• Formulate clinically credible, compliant queries for the medical staff to ensure accurate and complete documentation.
• Complete timely follow up on all cases; especially those with physician queries (every 1-2 days).
• Communicate with HIM coding staff to resolve MSDRG discrepancies.
• Utilize monitoring tools to track progress of the CDI program.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Religious, Grantmaking, Civic, Professional, and Similar Organizations
• Education Level: Associate degree
• Number of Employees: 1-10 employees