Clinical Documentation Spec - HIM-Clinical Doc Integrity - 016

Texas Children's Medical Center • Houston, TX

1d

About The Position

Description Job Duties & Responsibilities Daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information, and treatment plans. Ensures that the medical record documentation provides an accurate representation of the patient’s clinical care, diagnosis, severity, and expected risk of mortality sufficient to support APR-DRG assignment. Communicates with physicians and other healthcare team members, face to face or via clinical documentation inquiry forms regarding missing, unclear, or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness. Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team. Utilizes nursing critical thinking to identify clinical indicators for potential physician queries. Provides concurrent review and analysis of clinical information through electronic medical record review and interactions with providers. Acts as a liaison between hospital’s medical staff and coding/CDI team. Fosters cooperative relationships between medical staff and all CDI team. Participation in process improvement and education for CDI program. Reporting and analysis of data for CDI program. Actively participates in departmental and hospital committees and assigned Task Force groups Complies with HIPAA (Health Insurance Portability and Accountability Act of 1996) and all Hospital Policies and Procedures. Maintains interaction with appropriate resources that support growth and education of the CDI team. As part of our commitment to maintaining a safe and healthy workplace, all successful candidates will be required to undergo respiratory fit testing in compliance with occupational health and safety standards. Skills & Requirements

Requirements

• Required associate degree with a preferred bachelor's degree
• MDL - Medical Doctor License Texas Medical Board
• RN - Lic-Registered Nurses Texas Board of Nursing or Nurse Licensure Compact
• PA - Cert-Physician Assistant Texas Medical Board
• RHIA - Cert-Reg Health Inform. Admins American Health Information Management Association (AHIMA)
• RHIT - Cert-Reg Health Inform. TECH American Health Information Management Association
• CCS - Cert-Cert Coding Specialist American Health Information Management Association
• CPC - Cert-Cert Professional Coder America Association of Professional Coders
• CCDS DOC - Cert-Cert Clinical Doc. SPCLST Association of Clinical Documentation Improvement Specialist
• CDIP - Cert-Clinical Doc. Impr. PROF American Health Information Management Association

Nice To Haves

• Preferred Pediatric experience
• Nurse with an associate or preferably a bachelor's degree in nursing, NP, PA, MD
• Pediatric nursing experience

Responsibilities

• Daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information, and treatment plans.
• Ensures that the medical record documentation provides an accurate representation of the patient’s clinical care, diagnosis, severity, and expected risk of mortality sufficient to support APR-DRG assignment.
• Communicates with physicians and other healthcare team members, face to face or via clinical documentation inquiry forms regarding missing, unclear, or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness.
• Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team.
• Utilizes nursing critical thinking to identify clinical indicators for potential physician queries.
• Provides concurrent review and analysis of clinical information through electronic medical record review and interactions with providers.
• Acts as a liaison between hospital’s medical staff and coding/CDI team.
• Fosters cooperative relationships between medical staff and all CDI team.
• Participation in process improvement and education for CDI program.
• Reporting and analysis of data for CDI program.
• Actively participates in departmental and hospital committees and assigned Task Force groups
• Complies with HIPAA (Health Insurance Portability and Accountability Act of 1996) and all Hospital Policies and Procedures.
• Maintains interaction with appropriate resources that support growth and education of the CDI team.
• As part of our commitment to maintaining a safe and healthy workplace, all successful candidates will be required to undergo respiratory fit testing in compliance with occupational health and safety standards.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees