CLIN DOCUMENTATION SPEC I

Methodist Health System

Dallas (TX)

Remote

USD 75,000 - 110,000

Full time

16 hours ago

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Job summary

Methodist Health System in Dallas, TX seeks a Clinical Documentation Specialist to review medical records concurrently to improve accuracy of severity of illness and documentation quality. You will interact with physicians, HIM professionals, and nursing staff to support patient care and compliance.

The RN requirement is essential; CCDS/CDIP/CCS are preferred, with at least two years hospital experience, and ability to work remotely with strong writing, analytical and interpersonal skills.

Qualifications

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
2 years hospital experience required; CDI/coding/utilization review a plus

Responsibilities

Manage multiple priorities: query follow-up, initial chart review, concurrent chart review, MS-DRG discrepancy resolution.
Input data accurately into the computerized system using available tools.
Communicate effectively with physicians and hospital staff.
Perform thorough initial and concurrent medical chart reviews for documentation improvement.
Verify diagnoses are documented with ICD-10 terms and clinically supported.
Formulate credible queries to ensure complete documentation.
Follow up on cases, especially physician queries, every 1-2 days.
Collaborate with HIM coding staff to resolve MS-DRG discrepancies.
Use monitoring tools to track CDI program progress.
Demonstrate self-management and accountability while working remotely.

Skills

Critical thinking

Organizational skills

Analytical skills

Writing skills

Interpersonal skills

Education

Bachelor's degree in Nursing

Job description

Hours of Work

8 hrs/day

Days Of Week

Work Shift

8X5 Day (United States of America)

Job Description

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.

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.
Demonstrate strong self-management and accountability while working remotely.

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.

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