Clinical Documentation Specialist - Outpatient

Clinical Documentation Specialist – Outpatient

Texas Children's Hospital is looking for an Outpatient Clinical Documentation Specialist who works well in a fast‑paced setting. In this position you will be responsible for activities that improve the accuracy of facility outpatient clinical documentation and charging through retrospective chart review and claims audits. Additionally, you will provide education with clinical departments and conduct root‑cause correction to support accurate charging and coding in compliance with 영hospital/Health System policies.

The OP CDS assists clinical areas in effectively documenting services mindestens und understanding the relationship between documentation, medical necessity, and charging for services provided in accordance with Hospital/Health System policies and procedures.

• Chart audits and review of clinical workflows to evaluate opportunities to implement charge capture best practices.
• Conduct chart reviews of assigned clinical departments to regularly review documentation and charge accuracy and to integrate into educational sessions with clinical departments and medical staff.
• Conduct auditing and monitoring of assigned areas.
• Perform review of accounts identified as potentially missing charges and conduct additional research to help resolve the areas of opportunity and identify the root cause of the issues causing missed charges.
• Maintain current knowledge of applicable regulatory standards, which may impact utilization of processes and systems.
• Lead process improvement and education of clinical, CDI, and coding teams.
• Report and analyze data for discussion with clinical or financial teams.
• Have strong, in‑depth knowledge of CPT and HCPCS coding methodologies, as well as an understanding of CMS compliance regulations as they relate to hospital outpatient coding.

• Required associate degree with a preferred bachelor’s degree.
• Required Licenses/Certifications (one of the following):
• MDL – Medical Doctor License by the Texas Medical Board
• RN – Lic‑Registered Nurses by the Texas Board of Nursing or Nurse Licensure Compact
• PA – Cert‑Physician Assistant by the Texas Medical Board
• RHIA – Cert‑Reg Health Inform. Admins by the American Health Information Management Association (AHIMA)
• RHIT – Cert‑Reg Health Inform. TECH by the American Health Information Management Association
• CPC – Cert‑Cert Professional Coder by the America Academy of Professional Coders
• COC – Certified Outpatient Coder by the America Academy of Professional Coders
• CCS – Cert‑Cert Coding Specialist by the American Health Information Management Association
• CDEO – Certified Documentation Expert Outpatient by the America Academy of Professional Coders
• CCDS DOC – Cert‑Cert Clinical Doc. SPCLST by the Association of Clinical Documentation Improvement Specialistებია
• CDIP – Cert‑Clinical Doc. Impr. PROF by the American Health Information Management Association
• Required 5 years healthcare‑related experience with preferred pediatric experience in lax hospital outpatient charging, coding, and/or revenue capture functions and knowledge of APC and OPPS reimbursement structures.

Seniority level:
Mid‑Senior level

Employment type:

Full‑time

Job function:
Health Care Provider;
Industries:
Hospitals and Health Care

Since 1954, Texas Children’s has been leading the charge in patient care, education, and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children’s hospital in Texas, and among the top in the nation by U.S. News & World Report as well as recognition from Houston Business Journal as one of this city’s Best Places to Work for ten consecutive years.

Texas Children’s comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Tower for pediatric research;
Texas Children ’s Pavilion for Women unloading comprehensive…