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Clinical Documentation Specialist

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POST DATE 5/18/2017
END DATE 8/12/2017

Methodist The Woodlands, TX

The Woodlands, TX
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Entry Level (0 - 2 years)
Bachelors Degree


Job Summary

Responsible for improving the overall quality and completeness of clinical documentation. Promotes a partnership between the concurrent clinical reviewers, medical record coders, and physicians to improve documentation for the Hospital. Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians advocating for appropriate demonstration of the intensity of service and severity of illness relative to the patients care, resources consumed and the level of services rendered. Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patients true severity of illness and intensity of care. Educates all members of the health care team on an ongoing basis.


1. Promotes clarification of clinical documentation and documentation thoroughness to ensure that appropriate and accurate coding occurs relevant to the level of services rendered to all patients.

2. Demonstrates knowledge of DRG assignment and methodology, coding practices and clinical documentation requirements.

3. Improves overall quality and completeness of clinical documentation by performing concurrent record reviews using clinical documentation guidelines.

4. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.

5. Completes CDMP documentation data base worksheets to include clinical findings relevant to assignment of a working DRG. Request physician clarification of unclear diagnoses, complications, procedures and clinical documentation. Updates CDMP worksheets to reflect changes in status, procedures/treatments. Conducts follow up reviews of clinical documentation to ensure points of clarification have been recorded in the patient record. Reviews clinical issues with coding staff when necessary to determine working DRG assignment.

6. Educates internal customers on clinical documentation opportunities, coding, and profiling.

7. Demonstrates accountability and professional development. Attends coding clinics, stays updated on coding guidelines.

8. Demonstrates the components for the I CARE Value Statements (Integrity, Compassion, Accountability, Respect, Excellence) with patients, visitors, physicians and other employees at all times.

9. Demonstrates Service Pride Standards. (Smiles and makes eye contact, greets patients and visitors, displays appropriate body language, takes 5 minutes each day to go above and beyond, honors diversity, thanks every customer).

10. Follows all Safety rules. Reports all accidents and safety hazards promptly; communicates with peers and management regarding any hazards identified in the work place.

11. Assists with special projects. Performs other duties as assigned.


Registered Nurse with current Texas licensure, BSN preferred.


At least five years recent clinical experience in a hospital setting. Utilization review or coding experience is preferred.


Requires excellent observation skills, analytical thinking, problem solving, and good verbal and written communication and computer skills. Needs excellent organization/time management, prioritization skills and the ability to multitask.


Regular significant contacts with other personnel both internal (including but not limited to physicians, ancillary department personnel, Clinical Documentation Specialist, HIM, management) and others outside of the Methodist Healthcare System. Contacts may be: by telephone, in person, through written correspondence or e-mail. Requires assertiveness, even temperament, a pleasing personality and the ability to communicate easily with others.


Essential physical requirements: Sitting, standing, walking, bending, pushing, squatting and lifting.


Normal hospital conditions with-in a multiple building facility.
Equal Employment Opportunity

Houston Methodist is an Equal Opportunity Employer.

Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law.

VEVRAA Federal Contractor priority referral Protected Veterans requested.

Company Profile

Houston Methodist The Woodlands will be the eighth in the Houston Methodist system, offering The Woodlands community a full-service, acute care hospital with many of the same services as our flagship hospital in the Texas Medical Center. The $380 million campus will feature a new 187-bed, 470,000-square-foot facility. APPLY.


At Houston Methodist, Leading Medicine is more than a description of what we do; it's who we are. We take our responsibility as Houston's premier health care system seriously, and with a national reputation for excellence in patient care, innovation and research, we hold ourselves and the careers we build to a higher standard. Our culture is diverse, dynamic and challenging. We believe in our I Care Values and conduct ourselves with Integrity, Compassion, Accountability, Respect for others and a commitment to Excellence. Discover the difference for yourself and join Houston Methodist.

Company Size:
5,001-10,000 Employees
Health Care
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8100 Greenbriar
Houston, TX 77030

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