Clinical Documentation Specialist RN

Come lead with us at Corporate

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.

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

Quality / Safety Essential Functions

Finance Essential Functions

Growth / Innovation Essential Functions

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.

EDUCATION

Work Experience

Licenses And Certifications - Required

Licenses And Certifications - Preferred

KNOWLEDGE, SKILLS, AND ABILITIES

Supplemental Requirements

WORK ATTIRE

ON-CALL

TRAVEL

Houston Methodist is an Equal Opportunity Employer.