Clinical Documentation Specialist - Memorial Hermann Hospital
Title Clinical Documentation Specialist
Location 909 Frostwood,Houston,TX 77024
Category Revenue Cycle
Type Full time
At Memorial Hermann, we’re about creating exceptional experiences for both our patients and our employees. Our goal is to provide opportunities for our diverse employee population that develop and grow careers in a team-oriented environment focused on patient care. Every employee, at every level, begins their journey at Memorial Hermann learning about the history of the organization and its established culture built on trust and integrity. Our employees drive this culture, and we want you to be a part of it.
This position is responsible for concurrent review of inpatient medical records in order to identify opportunities for improving the quality of physician documentation. This position facilitates modifications to clinical documentation through concurrent interaction with physicians (verbally and electronically) and other members of the health care team. The goal of this position is to achieve a complete medical record in order to support complete, accurate and timely coding. Typically reports to the Regional Manager, Clinical Documentation Integrity. New positions are available at the following MH Hospital locations: The Woodlands Greater Heights Southeast Southwest Katy Texas Medical Center Campus Positions are all days, M-F, 8 to 5. Experience as a Clinical Documentation Specialist is highly desired. Acute care nursing experience required if no CDI experience to include in Med Surg, ICU, PACU.
Education: Graduate of an accredited school of professional nursing or Graduate of an accredited School of Medicine
RN license or Medical license (any state)
If unlicensed, ECFMG certification or CCS/CCS-P or RHIA/RHIT or CDIP certification through AHIMA or CCDS required
Regardless of licensure, CCDS certification from Association of Clinical Documentation Improvement Specialists (ACDIS) required for all within 1 year of meeting CCDS eligibility(2 Years of full time CDI work required to sit for CCDS)
Three (3) years of clinical experience in an acute care setting required, five (5) years preferred
Critical care experience or knowledge preferred
Working clinical knowledge of many areas of medicine
Detail oriented, with excellent analytical thinking, and problem solving skills
Ability to assess, evaluate and teach with effective oral and written communication skills
Proficient in utilizing: EMR documentation platforms, with Cerner experience a plus; Microsoft Office software (e.g. Word, PowerPoint, and Excel.)
Proficient in organization, planning and execution to ensure quality and productivity in work effort
Demonstrates adaptability, flexibility, and self-motivation, and an ability to work independently
Knowledge of federal, state and private payor regulations related to documentation and coding for the hospital inpatient setting preferred
Strong interpersonal skills and ability to interact in a positive fashion with physicians, CDI team members and other Memorial Hermann employees
Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of “we advance health” through innovation, accountability, empowerment, collaboration, compassion and results while ensuring One Memorial Hermann.
Responsible for the day-to-day review and evaluation of electronic documentation by the medical staff and healthcare team in accordance with MHHS CDI Department Policies and Procedures and CMS rules and regulations for documentation and coding.
Efficiently and productively utilizes the hospital’s EMR and designated CDI/Coding software systems to: review medical records, identify all opportunities for improved physician and hospital outcomes, and query physicians electronically/verbally, in order to obtain needed documentation prior to records being coded.
Responsible for the accurate capture of record review and query data, and calculation of accurate documentation performance measures to ensure report integrity/accuracy for leadership, medical staff, and other departments.
Communicates with physicians, coders, and other healthcare team members to facilitate comprehensive medical record documentation of diagnoses evaluated/treated, and procedures performed.
Identifies opportunities and trends variances to strategically direct provider education, and improve provider documentation.
Assists in the development of physician education to promote complete and accurate clinical documentation and correct negative trends via tip sheets, tip cards, meeting handouts, or PowerPoint presentations.
Researches literature on ACDIS website and stays abreast of annual changes to CMS/Coding rules and regulations, and Quarterly Coding Clinics, incorporating changes into daily practice for overall documentation improvement.
Conferences individually with key physicians to review regulations and coaches them to improve their documentation so it more accurately reflects the intensity of service, severity of illness, and risk of mortality of their patients, in order for coding to capture the most accurate ICD codes, DRG, SOI, and ROM designation.
Provides education to all internal customers related to compliance, coding, and clinical documentation issues/opportunities and acts as an internal consultant to these customers, when additional documentation is needed to assign the correct DRG, SOI or ROM.
Attends various hospital service line meetings, reviewing outcome information/reports, auditing records and educating physicians on service line specific improvement opportunities.
Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
Other duties as assigned