Clinical Documentation Specialist

Houston Methodist • Dallas, TX

392d • Remote

About The Position

The Clinical Documentation Specialist at Houston Methodist is responsible for enhancing the quality and completeness of clinical documentation. This role involves analyzing medical records, identifying trends, and facilitating modifications to documentation through collaboration with healthcare professionals to ensure appropriate reimbursement and accurate reporting of clinical outcomes.

Requirements

• Associate's or bachelor's degree in nursing or medical school graduate.
• For RN: At least five years of recent clinical experience in an acute care hospital setting.
• For Medical School graduate: One year of clinical experience preferred.
• Registered Nurse licensure in Texas or Compact State within 60 days.
• CCDS, CDIP, or CCS certification for Medical School graduates.

Nice To Haves

• Coding and utilization review experience preferred.

Responsibilities

• Analyze medical records for DRGs, complications, and comorbidities.
• Identify trends and make recommendations for documentation improvement.
• Facilitate modifications to clinical documentation through interaction with physicians and nursing staff.
• Support the accuracy of clinical information for measuring physician and hospital outcomes.
• Educate the patient care team on clinical documentation and coding issues.
• Conduct follow-up reviews of clinical documentation to ensure clarity in patient charts.
• Request clarification from physicians for unclear diagnoses and clinical information.

Benefits

• Comprehensive health insurance coverage.
• Retirement savings plan options.
• Professional development opportunities.
• Employee discounts on services and products.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Nursing and Residential Care Facilities
• Education Level: Associate degree
• Number of Employees: 10,001+ employees