Clinical Documentation Specialist

Houston Methodist • Houston, TX

5d

About The Position

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. Seeks additional information regarding clinical condition from appropriate clinical personnel and follows up as necessary. Tracks responses and trends completion of DRG/Documentation worksheets as pertinent to scope of department. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart. 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. Helps identify appropriate ICD10 codes for diagnoses or procedures related to projects or studies being conducted as needed. 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. Impacts discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, conferring with physician to finalize diagnosis as necessary. Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies

Requirements

• Medical School graduate where Western Medicine is practiced
• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
• 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
• Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures
• Demonstrates accountability and professional development
• Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
• Requires assertiveness while being even tempered, with a pleasing personality and the ability to communicate easily with others.

Nice To Haves

• One year of clinical experience preferred
• CCDS - Clinical Documentation Specialists (ACDIS) or CDIP - Certified Documentation Integrity Practitioner (AHIMA) or CCS - Certified Coding Specialist (AHIMA)

Responsibilities

• 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.
• Seeks additional information regarding clinical condition from appropriate clinical personnel and follows up as necessary.
• Tracks responses and trends completion of DRG/Documentation worksheets as pertinent to scope of department.
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart.
• 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.
• Helps identify appropriate ICD10 codes for diagnoses or procedures related to projects or studies being conducted as needed.
• 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.
• Impacts discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, conferring with physician to finalize diagnosis as necessary.
• Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Ph.D. or professional degree
• Number of Employees: 5,001-10,000 employees