Job Description

Clinical Documentation Specialist

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. 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.

Houston Methodist Standard

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

• 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 organization's vision, fulfills the mission and abides by the I CARE values

Responsibilities

PEOPLE ESSENTIAL FUNCTIONS

• 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.

SERVICE ESSENTIAL FUNCTIONS

• 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 patient's chart.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• 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.

FINANCE ESSENTIAL FUNCTIONS

• 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.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

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

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.

Qualifications

EDUCATION

• Associate's or bachelor's degree in nursing; OR

• Medical School graduate where Western Medicine is practiced

WORK EXPERIENCE

• 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

• For Medical School graduate - One year of clinical experience preferred

License/Certification

LICENSES AND CERTIFICATIONS - REQUIRED

• RN - Registered Nurse - Texas State Licensure and/or Compact State Licensure within 60 days OR
• RN-Temp - Registered Nurse - Temporary State Licensure within 60 days
• CCDS - Clinical Documentation Specialists (ASDIS) -- For Medical School graduate OR
• CDIP - Certified Documentation Integrity Practitioner (AHIMA) -- For Medical School graduate OR
• CCS - Certified Coding Specialist (AHIMA) -- For Medical School graduate

KSA/ Supplemental Data

KNOWLEDGE, SKILLS, AND ABILITIES

• 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*

• On Call* No

TRAVEL**

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

Company Profile

Houston Methodist (HM) is one of the nation's 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 25,000 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

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