Clin Documentation Spec I

Methodist Health System•Dallas, TX

2d•Remote

About The Position

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.

Requirements

Graduate from an accredited school of nursing.
RN – required
Basic computer skills
Critical thinking/problem-solving skills
Organizational, analytical, writing and interpersonal skills
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.
Demonstrate strong self-management and accountability while working remotely.