CLIN DOCUMENTATION SPEC I

Methodist Health System

United States

Remote

USD 65,000 - 90,000

Full time

4 days ago

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Job summary

Methodist Health System invites applications for a Clinical Documentation Specialist who reviews medical records to improve severity-of-illness documentation. The role requires an RN, preferably with CCDS/CDIP/CCS, and a minimum of two years hospital experience, ideally in ICU/CCU or med/surg CDI or utilization review.

The position emphasizes independent work, strong communication with physicians and staff, and the ability to manage multiple priorities. remote work is supported.

Qualifications

RN license is required; CCDS, CDIP, CCS are preferred
Bachelor degree preferred
Basic computer skills
Critical thinking and problem-solving skills
Organizational, analytical, writing and interpersonal skills
2 years of hospital experience required, ICU/CCU or strong med/Surg CDI/ coding/utilization review experience is a plus

Responsibilities

Manage multiple priorities: query follow-up, initial chart review, concurrent chart review, MS-DRG discrepancy resolution
Accurate input of data into the computerized system using provided tools
Communicate effectively with physicians and hospital staff
Perform initial and concurrent medical chart reviews to identify opportunities for documentation improvement
Verify documentation uses ICD-10 terms and is clinically supported
Formulate compliant physician queries to ensure complete documentation
Follow up on all cases every 1–2 days
Collaborate with HIM coding staff to resolve MSDRG discrepancies
Use monitoring tools to track CDI program progress
Demonstrate self-management and accountability while working remotely

Skills

Critical thinking

Analytical skills

Writing

Interpersonal skills

Organizational skills

Education

RN license

Bachelor's degree preferred

Job description

Hours of Work :

8 hrs/day

Days Of Week :

Work Shift :

8X5 Day (United States of America)

Job Description :

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.

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.

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. Our reputation as an award-winning employer shows in the distinctions we’ve earned: