Clinical Documentation Specialist (Remote) must live in TX, LA, WA, FL or GA

Overview

At Houston Methodist, the Clinical Documentation Specialist 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 role 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 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. Houston Methodist Standard PATIENT AGE GROUP(S) AND POPULATION(S) SERVED Refer to departmental "Scope of Service" and "Provision of Care" plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity. HOUSTON METHODIST EXPERIENCE EXPECTATIONS

• Provide personalized care and service by consistently demonstrating our I CARE values:
• INTEGRITY: We are honest and ethical in all we say and do.
• COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
• ACCOUNTABILITY: We hold ourselves accountable for all our actions.
• RESPECT: We treat every individual as a person of worth, dignity, and value.
• EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.
• Practices the Caring and Serving Model
• Delivers personalized service using HM Service Standards
• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)
• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees' experiential journeys to ensure strong communication, ease of access to information, and a seamless experience
• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job
• Actively supports the organization's vision, fulfills the mission and abides by the I CARE values Responsibilities 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 This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

Qualifications

EDUCATION

• Medical School graduate where Western Medicine is practiced WORK EXPERIENCE
• One year of clinical experience preferred License/Certification LICENSES AND CERTIFICATIONS - REQUIRED
• N/A LICENSES AND CERTIFICATIONS - PREFERRED
• CCDS - Clinical Documentation Specialists (ACDIS) OR
• CDIP - Certified Documentation Integrity Practitioner (AHIMA) OR
• CCS - Certified Coding Specialist (AHIMA) KSA/ Supplemental Data KNOWLEDGE, SKILLS, AND ABILITIES
• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined thro

Apply tot his job Apply To this Job