Clinical Documentation Specialist, RN

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🕒 June 27

🐊 Florida, Louisiana, +2 more states – Remote

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

⏰ Full Time

🟢 Junior

🏥📝 Medical Writer

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Houston Methodist

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

📚 Education

Healthcare • Education

Houston Methodist is an integrated health system based in Houston, TX. It operates multiple hospitals (including Houston Methodist Hospital, Sugar Land, The Woodlands, West, Cypress, Willowbrook, Baytown, Clear Lake, Continuing Care), a physician organization and primary care group, an academic institute, research and education programs, and international patient services. The organization runs extensive hiring and training programs for clinicians and staff, offers specialty and primary care services, and supports community and research initiatives.

📋 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.

🎯 Requirements

• 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

🏖️ Benefits

• Business professional attire