Job Description

Clinical Documentation Specialist (Remote) - must live in TX, LA, WA, FL or GA Houston Methodist is hiring a Clinical Documentation Specialist (Remote). The role requires residence in Texas, Louisiana, Washington, Florida, or Georgia. 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 DRGs, complications, and comorbidities; identifies trends; and notes observations and recommendations for documentation improvement. The 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 appropriate reimbursement. 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. 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 ICD-10 codes for diagnoses or procedures related to projects or studies being conducted as needed. Finance Essential Functions: Promotes clarification to clinical documentation to ensure appropriate reimbursement for the level of service rendered. Identifies diagnoses and procedures performed and comorbidities/complications. Impacts discharges by updating the DRG worksheet to reflect changes in status, procedures/treatments, conferring with physician to finalize diagnosis as necessary. Growth/Innovation Essential Functions: Educates 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. Education Medical School graduate where Western Medicine is practiced Work Experience One year of clinical experience preferred Licenses and Certifications - Required N/A Licenses and Certifications - Preferred CCDS - Clinical Documentation Specialist (ACDIS) OR CDIP - Certified Documentation Integrity Practitioner (AHIMA) OR CCS - Certified Coding Specialist (AHIMA) Knowledge, Skills, and Abilities Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills assessments and performance evaluations Proficiency in speaking, reading, and writing English necessary to perform essential functions, especially where activities impact safety Ability to effectively communicate with patients, physicians, family members, and coworkers with a customer service focus Knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures Demonstrates accountability and professional development Strong observation, analytical thinking, problem solving, and verbal/written communication Regular significant contacts with personnel across the institution; ability to be assertive while maintaining a calm, personable demeanor Supplemental Requirements Work Attire : Business professional On-Call : Not required, may be required during emergencies Travel : Travel specifications may vary by department; may require travel within or outside the Houston Metropolitan area Houston Methodist is an Equal Opportunity Employer. Senior ity level Entry level Employment type Full-time Job function Health Care Provider Industries: Hospitals and Health Care Referrals increase your chances of interviewing at Houston Methodist. #J-18808-Ljbffr Houston Methodist

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