Clinical Documentation Specialist RN (Remote) must live in TX, LA, WA, FL or GA

HOUSTON METHODIST EXPERIENCE EXPECTATIONS

• Provide personalized care and service by consistently demonstrating our I CARE values:
  • INTEGRITY: We are honest and ethical in all we say and do.
  • COMPASSION: We embrace the whole person including emotional ethical physical and spiritual needs.
  • ACCOUNTABILITY: We hold ourselves accountable for all our actions.
  • RESPECT: We treat every individual as a person of worth dignity and value.
  • EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.

• Practices the Caring and Serving Model

• Delivers personalized service using HM Service Standards

• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET Managing Up Key Words)

• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees experiential journeys to ensure strong communication ease of access to information and a seamless experience

• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

• Actively supports the organizations vision fulfills the mission and abides by the I CARE values

• 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 patients 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 that 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 conferring with physician to finalize diagnosis as necessary.

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

• Medical School graduate where Western Medicine is practiced

• One year of clinical experience preferred

• N/A

• CCDS - Clinical Documentation Specialists (ACDIS) OR
• CDIP - Certified Documentation Integrity Practitioner (AHIMA) OR
• CCS - Certified Coding Specialist (AHIMA)

• Demonstrates the skills and competencies necessary to safely perform the assigned job determined through on-going skills competency assessments and performance evaluations

• Sufficient proficiency in speaking reading and writing the English language necessary to perform the essential functions of this job especially with regard to activities impacting patient or employee safety or security

• Ability to effectively communicate with patients physicians family members and co-workers in a manner consistent with a customer service focus and application of positive language principles

• Demonstrates knowledge of DRG payor issues appropriate DRG assignment alternatives clinical documentation requirements and referral policies and procedures

• Demonstrates accountability and professional development

• Requires excellent observation skills analytical thinking problem solving plus good verbal and written communication

• Regular significant contacts with other personnel throughout the institution (including but not limited to - physicians and their staff mid-level providers mid-level staff coders Case Managers). Contacts may be in person by telephone or through correspondence. Requires assertiveness while being even tempered with a pleasing personality and the ability to communicate easily with others.

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) No

ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. DIsaster Severe Weather Events etc) regardless of selection below.

• On Call* No

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area No
• May require travel outside Houston Metropolitan area No

Houston Methodist (HM) is one of the nations leading health systems and academic medical centers. HM consists of eight hospitals: Houston Methodist Hospital its flagship academic hospital in the heart of the Texas Medical Center and seven community hospitals throughout the greater Houston metropolitan area. HM also includes an academic institute a comprehensive residency program a global business division numerous physician practices and several free-standing emergency rooms and outpatient facilities. Overall HM employs over 25000 employees. Houston Methodist is supported by a wide variety of business functions that operate at the system level to help enable clinical departments to provide the best patient care and service in a spiritual environment.

In 2019 Houston Methodist and its physicians treat more than 6333 international patients from more than 76 countries. Houston Methodist Global Health Care Services consulting and education divisions also provide advisory services and training and development to health care organizations around the world.