Clinical Documentation Specialist RN

About the role

The Clinical Documentation Specialist RN position at Corporate At Houston Methodist is responsible for improving the overall quality and completeness of clinical documentation. This includes analyzing medical records for DRG's, complications, and comorbidities; identifying trends; and noting observations and recommendations for documentation improvement. Additionally, this position facilitates modifications to clinical documentation through interactions with physicians, nursing staff, other patient care givers, and medical records coding staff.

Responsibilities

• Improves the overall quality, completeness and accuracy of clinical documentation by performing open record reviews using clinical documentation guidelines.
• Serves as a resource for clinical documentation, ensuring accurate and complete clinical information used for measuring and reporting physician and medical outcomes.
• Seeks additional information regarding clinical conditions from appropriate clinical personnel and follows up as necessary.
• Tracks responses and trends completion of DRG/Documentation worksheets as pertinent to department scope.
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
• 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 ICD10 codes for diagnoses or procedures related to projects or studies being conducted as needed.
• Promotes clarification to clinical documentation to ensure appropriate reimbursement is received for the level of service rendered to all patients.
• Identifies diagnoses and procedures performed and comorbidities and complications.
• Impacts discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, and conferring with physicians to finalize diagnosis as necessary.
• Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies.

Qualifications

• Graduate of an education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section.
• Five years of recent clinical experience caring for adults in an acute care hospital setting.
• Coding and utilization review experience preferred.

Requirements

• Required RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency).
• Preferred CCDS - Clinical Documentation Specialists (ACDIS) or CDIP - Certified Documentation Integrity Practitioner (AHIMA) or CCS - Certified Coding Specialist (AHIMA).