Clinical Documentation Specialist — Elevate Patient Records & Coding

CORP - HM Corporate Division - The Methodist Hospital; Clear Lake (TX); On-site; USD 60,000 - 90,000; Full time

Job summary

Houston Methodist is seeking a non-clinical professional to enhance clinical documentation quality and completeness. The role involves open record reviews, DRG-related coding practices, and collaboration with physicians and care teams to obtain needed clarifications.

The position emphasizes accurate documentation, communication skills, and accountability to ensure proper reimbursement. Exempt, full-time status based in Texas with on-site work expectations.

Qualifications

• Medical school graduate with Western Medicine practice.
• One year of clinical experience preferred.

Responsibilities

• Improves the overall quality, completeness and accuracy of clinical documentation through open record reviews and adherence to clinical documentation guidelines.
• Seeks additional information from clinical personnel and follows up to complete DRG/Documentation worksheets.
• Conducts follow-up reviews to ensure points of clarification are recorded in patients' charts.
• Identifies ICD10 codes for diagnoses or procedures and communicates with physicians for clarification or corrections.
• Educates internal customers on clinical documentation opportunities, coding, and reimbursement issues.

Skills

Clinical documentation

English proficiency

Communication

DRG knowledge

Documentation quality

Accountability

Attention to detail

Education

Medical School graduate (Western Medicine)

CCDS (ACDIS) or CDIP or CCS

Job description

Houston Methodist is seeking a non-clinical professional to enhance clinical documentation quality and completeness. The role involves open record reviews, DRG-related coding practices, and collaboration with physicians and care teams to obtain needed clarifications.

The position emphasizes accurate documentation, communication skills, and accountability to ensure proper reimbursement. Exempt, full-time status based in Texas with on-site work expectations.