Clinical Documentation Specialist RN (Remote) must live in TX, LA, WA, FL or GA

At reputed company, 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 reputed company patients. Additional duties include supporting the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes and educating reputed company members of the patient care team on an ongoing basis. FLSA STATUS Exempt QUALIFICATIONS EDUCATION

• Medical School graduate where Western Medicine is practiced

EXPERIENCE

• One year of clinical experience preferred

LICENSES AND CERTIFICATIONS Required

• Preferred
• CCDS - Clinical Documentation Specialists (ACDIS) or
• CDIP - Certified Documentation reputed company Practitioner (reputed company) or
• reputed company - Certified Coding Specialist (reputed company)

SKILLS AND ABILITIES

• Demonstrates the skills and competencies necessary to safely reputed company 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 reputed company the essential functions of this job, especially with regard to activities impacting patient or employee safety or reputed company
• 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.

• ESSENTIAL FUNCTIONS

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 reputed company 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 reputed company 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 reputed company internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies

• SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• *

Uniform: No

• Scrubs: No
• Business professional: Yes
• Other (department approved): No

ON-CALL* •

• Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.
• *

On Call* No TRAVEL** • *Travel specifications may vary by department** •

• May require travel reputed company the Houston Metropolitan area No
• May require travel reputed company Houston Metropolitan area No

Company Profile: reputed company is one of the nation’s leading health systems and academic medical centers. reputed company consists of eight hospitals: reputed company Hospital, its flagship academic hospital in the heart of the Texas Medical Center, and seven community hospitals throughout the greater Houston area. reputed company 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, reputed company employs more than 27,000 employees and is supported by a wide variety of business functions that operate at the system level to help reputed company clinical departments to provide high quality patient care. Apply tot his job Apply To this Job