Clinical Documentation Specialist

Education: Bachelor of Nursing required.

Licenses/Certifications:

• Current State of Texas license or temporary/compact license to practice professional nursing

Experience / Knowledge / Skills:

• Five (5) years of inpatient, acute care at the bedside on a nursing unit; ICU experience preferred

• Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication

• Possesses a working knowledge of many areas of adult medicine

• Able to assess, evaluate, and teach

• Proficiency in organization and planning

• Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching

• Ability and willingness to seek out and accept change

• Demonstrates adaptability, flexibility, and self-motivation, and an ability to work independently

• Knowledge of federal, state and private payer regulations preferred

• Professional, team player, able to communicate well with others

• Strong interpersonal skills and positive attitude

• Regular, significant contact with other personnel throughout and outside Memorial Hermann; Contact may be in person, by telephone, or through correspondence

Principal Accountabilities

• Communicates with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients.

• Utilizes the hospital’s designated clinical documentation system to identify opportunities for physician and hospital outcomes.

• Provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG.

• Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team in accordance with the hospital’s designated clinical documentation system.

• Gathers and analyzes information pertinent to documentation findings and outcomes.

• Contributes to a positive working environment and performs other duties as assigned or directed to enhance the overall efforts of the organization.

• Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends.

• Identifies patterns, trends variances and opportunities to improve documentation review and process.

• Researches literature and stays abreast of CMS rules and regulations, incorporating changes to daily practice for overall documentation enhancement.

• Assists in the development and reporting of performance measures to the medical s