CLIN DOCUMENTATION SPEC I

8 hrs/day, 5 days per week (8X5 Day shift)

About the Organization

Methodist Health System is a faith-based organization with a mission to improve and save lives through compassionate, quality healthcare. For nearly a century, Dallas-based Methodist Health System has been a trusted choice for health and wellness. Named one of the fastest-growing health systems in America, Methodist has a network of 12 hospitals (through ownership and affiliation) with nationally recognized medical services, such as a Level I Trauma Center, multi-organ transplantation, Level III Neonatal Intensive Care, neurosurgery, robotic surgical programs, oncology, gastroenterology, and orthopedics, among others. Methodist has more than two dozen clinics located throughout the region, renowned teaching programs, innovative research, and a strong commitment to the community.

Methodist Health System has earned numerous distinctions as an award-winning employer, including:

• Great Place to Work Certified 2026-2027
• Glassdoor’s Best Places to Work 2025 & 2026
• Glassdoor’s Best Places to Work in Healthcare, Biotech & Pharma 2026
• TIME’s Best Companies for Future Leaders 2025 & 2026
• Newsweek’s America’s Most Admired Workplaces 2026
• Glassdoor’s Best-Led Companies 2025
• Fortune Best Workplaces in Health Care 2025
• Military Friendly Gold Employer 2025
• Becker’s Hospital Review 150 Top Places to Work in Healthcare 2025
• Newsweek’s Americas Greatest Workplaces 2025

About the Role

The Clinical Documentation Specialist is responsible for reviewing medical records concurrently to facilitate accurate representation of severity of illness by improving the quality of the physicians' clinical documentation. This involves extensive record analysis, interaction with physicians, HIM professionals, and nursing staff.

Responsibilities

• Successfully manage multiple priorities: query follow-up, initial chart review, concurrent chart review, MS-DRG discrepancy resolution.
• Efficiently use tools provided for the position, including computer software.
• Accurately input data into the computerized system.
• Communicate effectively and appropriately with physicians and hospital staff.
• Perform thorough initial and concurrent medical chart reviews to identify opportunities for documentation improvement.
• Verify that all treated or monitored conditions are properly documented by the physician in the medical record using specific ICD-10 diagnostic terms.
• Verify that all documented diagnoses are clinically supported using industry-accepted diagnostic criteria.
• Formulate clinically credible, compliant queries for the medical staff to ensure accurate and complete documentation.
• Complete timely follow-up on all cases, especially those with physician queries (every 1-2 days).
• Communicate with HIM coding staff to resolve MS-DRG discrepancies.
• Utilize monitoring tools to track progress of the CDI program.
• Demonstrate strong self-management and accountability while working remotely.

Requirements

• Graduate from an accredited school of nursing.
• Bachelor's degree preferred.
• RN required; CCDS, CDIP, or CCS preferred.
• Basic computer skills.
• Critical thinking and problem-solving skills.
• Organizational, analytical, writing, and interpersonal skills.

Qualifications

• 2 years of recent hospital experience required, preferably in ICU, CCU, or strong med/surg.
• CDI, coding, or utilization review experience is a plus.