Details
JOB SUMMARY:This job can work remotely from the following States - GA, WA, FL, TN and TX
At Houston Methodist, the Lead Clinical Documentation Specialist is responsible for providing a second level of support, as directed by the Manager/Director, to the daily activities and responsibilities of the Clinical Documentation Specialists. This position is responsible for improving the overall accuracy, quality and completeness of clinical documentation and facilitates modifications through appropriate interaction with physicians, nursing staff, other patient care givers, and medical records coding staff advocating for appropriate reimbursement relative to the patient care resources consumed and the level of service rendered. Duties include supporting the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes and educating all members of the patient care team toward the documentation thoroughness for all patient populations on an ongoing basis. This position is a working lead position; lead duties may include many of the following: organize work schedules, make work assignments, conduct quality assurance audits of staff performance, train and mentor staff, provide feedback on staff performance and developmental needs, lead and regularly perform special projects, collect/analyze/report on data, and others of a similar nature.
PRIMARY JOB RESPONSIBILITIES
Job responsibilities labeled EF capture those duties that are essential functions of the job.
PEOPLE - 10%
- Orients, guides, and mentors team members and support staff to help build confidence and competency in skills, knowledge and abilities. Assists in interviewing and hiring of new staff. (EF)
- Interacts and communicates with Physician staff daily as needed - educating them in the process of clarifying documentation in the medical record. (EF)
SERVICE - 20%
- Assists Clinical Documentation Specialists and fills in as needed to cover the reviews daily. (EF)
- Educates all internal customers on clinical documentation opportunities, supporting coding guidelines, as well as performance improvement methodologies. (EF)
- Serves as a member of the Clinical Documentation Work Group. (EF)
QUALITY/SAFETY - 30%
- As directed by Manager/Director, provides second level of support to the daily activities and responsibilities of the Clinical Documentation Specialists identified in the defined process of DRG Assurance and the defined job description of the Clinical Documentation Specialist. (EF)
- Improves the overall quality and completeness of clinical documentation by performing record reviews using clinical documentation guidelines. (EF)
- Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes. (EF)
- Reviews clinical issues when appropriate with coding staff to assign a working DRG and/or clarification of documentation.
FINANCE - 30%
- Performs patient chart reviews during absences and when coverage is necessary. (EF)
- Promotes clarification of clinical documentation, advocating for appropriate reimbursement for the patient care resources consumed and the level of service rendered. (EF)
- Completes and updates the DRG Documentation Worksheet to include abstraction of patient clinical findings relevant to assign an on-going working DRG, Physician Documentation Request/Interactions and visit frequency reflecting any changes in status, procedures/treatments, and conferring with physician on the final diagnoses. (EF)
- Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart. (EF)
GROWTH/INNOVATION - 10%
- Attends coding clinics and stays updated on coding and documentation guidelines. (EF)
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 REQUIREMENTS
- Bachelor of Science in Nursing is required; Master of Science in Nursing or other master's degree in a related field preferred; OR
- Medical School graduate where Western Medicine is practiced
EXPERIENCE REQUIREMENTS
- Three years of recent CDI experience in an acute care hospital
- Academic hospital experience, previous CDI Lead experience, and/or coding experience preferred
CERTIFICATIONS, LICENSES AND REGISTRATIONS REQUIRED
- For RN - Texas RN license or temporary TX RN license, should obtain permanent license within 90 days. Compact license acceptable according to current Board of Nursing requirements. Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Improvement Specialists, Certified Documentation Improvement Practitioner (CDIP) through the American Health Information Management Association, or Certified Coding Specialist (CCS) through the American Health Information Management Association preferred.
- For Medical School graduate - Must have one of the following certifications:
- Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Improvement Specialists
- Certified Documentation Improvement Practitioner (CDIP) through the American Health Information Management Association
- Certified Coding Specialist (CCS) through the American Health Information Management Association
KNOWLEDGE, SKILLS AND ABILITIES REQUIRED
- 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
- Maintains 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 | Yes/No |
| Uniform | No |
| Scrubs | No |
| Business professional | Yes |
| Other (dept approved) | No |
| On-Call* | No (for Non-Exempt or Exempt jobs) |
*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Event, etc) regardless of selection above.
Travel**
| May require travel within | No |
| Houston Metropolitan area |
| May require travel outside | No |
| of Houston Metropolitan area |
**Travel specifications may vary by department.
Please note any other special considerations to this job: Flexibility to work more than 8 hours per day when needed or required
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 its physicians treated more than 6,333 international patients from more than 76 countries. Houston Methodist Global Health Care Services’ consulting and education divisions also provide advisory services and training and development to health care organizations around the world.