Clinical Documentation RN Specialist

Houstonmethodistcareers; Georgia; On-site; USD 85,000 - 110,000; Full time

Job summary

Houston Methodist is seeking a Clinical Documentation Specialist RN to improve the quality and completeness of clinical documentation. The role analyzes medical records for DRGs, complications, and comorbidities, and collaborates with physicians and staff to ensure appropriate reimbursement.

The specialist will support accuracy of data used for measuring outcomes and will educate the care team on documentation best practices. Exempt status and Texas licensing requirements apply.

Qualifications

• Five years of recent clinical experience caring for adults in an acute care hospital setting.
• RN license (TX) with permanent Texas license within 60 days if establishing residency.
• Preferred: CCDS, CDIP, CCS certifications.

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 hospital outcomes.
• Educates all members of the patient care team on clinical documentation, coding, and reimbursement issues, as well as performance improvement methodologies.
• Tracks responses and trends in DRG/Documentation worksheets pertinent to the scope of department.
• Demonstrates knowledge of DRG payor issues, optimization strategies, clinical documentation requirements and referral policies.

Skills

Clinical documentation

Communication

DRG knowledge

Analytical thinking

Quality improvement

Education

RN license TX

CCDS

CDIP

CCS

Job description

Houston Methodist is seeking a Clinical Documentation Specialist RN to improve the quality and completeness of clinical documentation. The role analyzes medical records for DRGs, complications, and comorbidities, and collaborates with physicians and staff to ensure appropriate reimbursement.

The specialist will support accuracy of data used for measuring outcomes and will educate the care team on documentation best practices. Exempt status and Texas licensing requirements apply.