Clinical Documentation Specialist RN

Houstonmethodistcareers; Louisiana (MO); On-site; USD 90,000 - 115,000; Full time

Job summary

Houston Methodist is seeking a Clinical Documentation Specialist RN to enhance the quality and completeness of clinical documentation in an acute care setting. You will analyze records for DRGs, interact with physicians and staff to ensure accurate reimbursement, and educate the care team on documentation best practices.

The role is Exempt, requires Texas RN licensure and 5 years of experience; CCDS/CDIP/CCS are preferred certifications.

Qualifications

• Five years of recent clinical experience in acute care.
• Coding and utilization review experience preferred.
• RN licensure in Texas; must obtain permanent Texas license within 60 days if relocating.
• Strong English reading, writing and communication for safety-critical tasks.

Responsibilities

• Analyze medical records for DRGs, complications and comorbidities.
• Identify trends and provide documentation improvement recommendations.
• Interact with physicians, nursing staff and coding staff to ensure appropriate reimbursement.
• Educate care team on clinical documentation opportunities and accuracy.

Skills

Observation skills

Analytical thinking

Problem solving

Verbal communication

Written communication

Customer service

Education

RN licensure (Texas)

CCDS (ACDIS)

CDIP (AHIMA)

CCS (AHIMA)

Job description

At Houston Methodist, the Clinical Documentation Specialist RN position is responsible for improving the overall quality and completeness of clinical documentation. This position analyzes medical records for DRG's, complications, and comorbidities; identifies trends; and notes observations and recommendations for documentation improvement. This Clinical Documentation Specialist RN position also facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients. Additional duties for this position include supporting the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes and educating all members of the patient care team on an ongoing basis.

FLSA STATUS

Exempt

EDUCATION

• Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section

EXPERIENCE

• Five years of recent clinical experience caring for adults in an acute care hospital setting
• Coding and utilization review experience preferred

LICENSES AND CERTIFICATIONS

Required

• RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)

Preferred

• CCDS - Clinical Documentation Specialists (ACDIS) or
• CDIP - Certified Documentation Integrity Practitioner (AHIMA) or
• CCS - Certified Coding Specialist (AHIMA)

KNOWLEDGE AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing 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
• Excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
• Regular significant contacts with other personnel throughout the institution (including but not limited to physicians and their staff, mid-level providers, mid-level staff, coders, Case Managers). Contacts may be in person, by telephone, or through correspondence
• Requires assertiveness while being even tempered, with a pleasing personality and the ability to communicate easily with others

ESSENTIAL FUNCTIONS

PEOPLE ESSENTIAL FUNCTIONS

• 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.

SERVICE ESSENTIAL FUNCTIONS

• 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.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• 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.

FINANCE ESSENTIAL FUNCTIONS

• 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.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies.

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform: No
• Scrubs: No
• Business professional: Yes
• Other (department approved): No

ON-CALL*

Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.

• On Call* No

TRAVEL**

Travel specifications may vary by department

• May require travel within the Houston Metropolitan area No
• May require travel outside Houston Metropolitan area No