Clinical Documentation Specialist RN; Remote

Clinical Documentation Specialist RN (Remote)

Join to apply for the Clinical Documentation Specialist RN (Remote) role at Houston Methodist
.

The candidate for this role must live in: TX, LA, WA, FL or GA.

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 comorbidities; identifies trends; and notes observations and recommendations for documentation improvement. The 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 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.

• Education: Medical School graduate where Western Medicine is practiced
• Experience: One year of clinical experience preferred
• Licenses &
  
  Certifications:
  
  
  • CCDS - Clinical Documentation Specialists (ACDIS)
  • CDIP - Certified Documentation Integrity Practitioner (AHIMA)
  • CCS - Certified Coding Specialist (AHIMA)
• Skills and Abilities:
  • Demonstrates competencies necessary for safety, assessed via ongoing evaluations
  • Proficiency in speaking, reading, and writing English necessary for patient and employee safety
  • Effectively communicates with patients, physicians, family members, and co‑workers in a customer‑service manner
  • Knowledge of DRG payor issues, DRG assignment alternatives, clinical documentation requirements, and referral policies
  • Demonstrates accountability and professional development
  • Excellent observation, analytical thinking, problem solving, and communication skills
  • Regular significant contacts with physicians, mid‑level providers, coders, and case managers, by phone or correspondence, with assertiveness and a pleasing personality

• Improves overall quality, completeness, and accuracy of clinical documentation by performing open record reviews using clinical documentation guidelines; supports accuracy of information used for measuring and reporting physician and medical outcomes.
• Seeks additional information regarding clinical condition from appropriate personnel and follows up as necessary; tracks responses and trends completion of DRG/Documentation worksheets as pertinent.
• Conducts follow‑up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
• Requests clarification or correction from physicians for unclear diagnoses, complications, procedures, and clinical information; assists staff in identifying appropriate ICD‑10 codes for diagnoses or procedures related to projects or studies.
• Promotes clarification to ensure appropriate reimbursement for service rendered to all patients; identifies diagnoses and procedures performed and comorbidities and complications; impacts discharges by updating DRG worksheet, collaborating with physicians to finalize diagnosis.
• Educates all internal customers on clinical documentation opportunities, coding, reimbursement issues, and performance improvement methodologies.

• Work Attire: Business professional:
  Yes;
  Uniform, Scrubs, Other:
  No.
• On‑Call: No; employees may be required to be on‑call during emergencies (disaster, severe weather events) regardless of selection.
• Travel: May require travel within the Houston Metropolitan area:
  No; outside Houston Metropolitan area:
  No.

Entry level

Full‑time

Health Care Provider

Hospitals and Health Care