Clinical Documentation Specialist, RN

🕒 il y a 1 mois

🐊 Florida, Louisiana, +2 états de plus – Distant

🐊 Florida – Remote ⚜️ Louisiana – Remote 🤠 Texas – Remote ☕ Washington – Remote

⏰ Temps Plein

🟢 Junior

🏥📝 Rédacteur Médical

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Houston Methodist

Site WebLinkedInTous les Emplois

10 000+ employés

🏥 Santé

📚 Éducation

Healthcare • Education

Houston Methodist est un système de santé intégré basé à Houston, au Texas. Il exploite plusieurs hôpitaux (dont Houston Methodist Hospital, Sugar Land, The Woodlands, West, Cypress, Willowbrook, Baytown, Clear Lake, Continuing Care), une organisation de médecins et un groupe de soins primaires, un institut académique, des programmes de recherche et d'éducation, ainsi que des services pour les patients internationaux. L'organisation mène des programmes de recrutement et de formation étendus pour les cliniciens et le personnel, propose des services de soins spécialisés et primaires, et soutient des initiatives communautaires et de recherche.

Description

• 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. • 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. • Requests clarification and/or correction from physicians for unclear diagnoses, complications, procedures, and clinical information. • Promotes clarification to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients.

🎯 Exigences

• Medical School graduate where Western Medicine is practiced • One year of clinical experience preferred • CCDS - Clinical Documentation Specialists (ACDIS) or CDIP - Certified Documentation Integrity Practitioner (AHIMA) or CCS - Certified Coding Specialist (AHIMA) • Sufficient proficiency in speaking, reading, and writing the English language • Knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures • Excellent observation skills, analytical thinking, and problem solving • Ability to communicate effectively with patients, physicians, and co-workers • Regular significant contacts with other personnel throughout the institution

🏖️ Avantages

• Business professional attire