At Houston Methodist, the Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation. This position analyzes medical records for DRG¿s, complications, and commodities; identifies trends; and notes observations and recommendations for documentation improvement. This role also facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients. Additional duties include supporting the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes and educating all members of the patient care team on an ongoing basis.
PATIENT AGE GROUP(S) AND POPULATION(S) SERVED
Refer to departmental "Scope of Service" and "Provision of Care" plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity.
HOUSTON METHODIST EXPERIENCE EXPECTATIONS
o 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.
o Focuses on patient/customer safety
o Delivers personalized service using HM Service Standards
o Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)
o Intentionally rounds with patients/customers to ensure their needs are being met
o Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job
PRIMARY JOB RESPONSIBILITIES
Job responsibilities labeled EF capture those duties that are essential functions of the job.
PEOPLE - 20%
1. 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. (EF)
SERVICE - 25%
1. 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. (EF)
2. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient¿s chart. (EF)
QUALITY/SAFETY - 25%
1. 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. (EF)
FINANCE - 20%
1. 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. (EF)
GROWTH/INNOVATION - 10%
1. Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies. (EF)
This job description is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.
o Associate¿s or bachelor¿s degree in nursing; OR
o Medical School graduate where Western Medicine is practiced
o For RN - At least five years of recent clinical experience caring for adults in an acute care hospital setting is required; coding and utilization review experience preferred
o For Medical School graduate - One year of clinical experience preferred
CERTIFICATIONS, LICENSES AND REGISTRATIONS REQUIRED
o For RN - Texas RN license or temporary TX RN license, should obtain permanent license within 90 days. Compact license acceptable according to current Board of Nursing requirements.
o For Medical School graduate Must have one of the following certifications:
o Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Improvement Specialists
o Certified Documentation Improvement Practitioner (CDIP) through the American Health Information Management Association
o Certified Coding Specialist (CCS) through the American Health Information Management Association
KNOWLEDGE, SKILLS AND ABILITIES REQUIRED
o Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
o 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
o 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
o Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures
o Demonstrates accountability and professional development
o Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
o 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.
Work Attire Yes/No
Business professional Yes
Other (dept approved) No
On-Call* No (for Non-Exempt or Exempt jobs)
- Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Event, etc) regardless of selection above.
May require travel within No
Houston Metropolitan area
May require travel outside No
of Houston Metropolitan area
**Travel specifications may vary by department.
Please note any other special considerations to this job:
Flexibility to work more than 8 hours per day when needed or required