CLINICAL DOCUMENTATION SPECIALIST Job Listing at The Methodist Hospital in Houston, Texas (Job ID meth-00055739)

Description:
Responsible for improving the overall quality and completeness of clinical documentation. 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. Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and medical center outcomes. Educates all members of the patient care team on an ongoing basis.

Promotes clarification to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients.

Demonstrates knowledge of DRG payor issues, optimization strategies, clinical documentation requirements and referral policies and procedures.

Improves that overall quality and completeness of clinical documentation by performing record reviews using clinical documentation guidelines.

Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical outcomes.

Process discharges by updating the DRG Worksheet to reflect any changes in status, procedures/treatments, conferring with physician to finalize diagnosis.

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

Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart.

Reviews clinical issues with the coding staff assign a working DRG and/or clarification of documentation.

Tracks response to Clinical Documentation Specialist and trends completion of DRG/Documentation worksheets.

Participates in patient care conferences to identify needs for clinical documentation, as appropriate.

All Documentation Specialist must adhere to all safety regulations.

All Documentation Specialists must have and show the ICARE attitude at all times to patients, visitors, physicians, and other employees.

Assist with special projects as needed and performs other job-related duties as assigned.

EDUCATION REQUIREMENTS
Registered Nurse with current Texas licensure, BSN preferred.
At least five years recent clinical experience in a hospital setting. Utilization review or coding experience is preferred.

EXPERIENCE REQUIREMENTS
At least five years recent clinical experience in a hospital setting. Utilization review or coding experience is preferred.

CERTIFICATES, LICENSES AND REGISTRATIONS REQUIRED
Current Texas License, BSN preferred.

SPECIAL KNOWLEDGE, SKILLS AND ABILITIES REQUIRED
Essential Technical/motor skills: requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication.

Interpersonal skill: Regular significant contacts with other personnel both internal and external. Contacts may be: telephone, in person, or through written correspondence. Requires mild mannered, even-tempered and pleasing personality, as well as the ability to communicate easily with others.