Job Description
Job Description We're hunting for a Clinical Documentation Specialist, someone who's ready to be part of the best ranked children's hospital in Texas, and among the best in the nation. In this position, you will function as the coordinator/educator for the Inpatient Documentation Improvement Program. The CDS improves the quality and completeness of clinical documentation in the patient record through extensive interaction with physicians, nursing staff, other patient caregivers, and HIM coding staff.
Think you've got what it takes?
Job Duties & Responsibilities •Daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information, and treatment plans.
•Ensures that the medical record documentation provides an accurate representation of the patient's clinical care, diagnosis, severity, and expected risk of mortality sufficient to support APR-DRG assignment.
•Communicates with physicians and other healthcare team members, face to face or via clinical documentation inquiry forms regarding missing, unclear, or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness.
•Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team.
•Utilizes nursing critical thinking to identify clinical indicators for potential physician queries.
•Provides concurrent review and analysis of clinical information through electronic medical record review and interactions with providers.
•Acts as a liaison between hospital's medical staff and coding/CDI team.
•Fosters cooperative relationships between medical staff and all CDI team.
•Participation in process improvement and education for CDI program.
•Reporting and analysis of data for CDI program.
•Actively participates in departmental and hospital committees and assigned Task Force groups
•Complies with HIPAA (Health Insurance Portability and Accountability Act of 1996) and all Hospital Policies and Procedures.
•Maintains interaction with appropriate resources that support growth and education of the CDI team.
As part of our commitment to maintaining a safe and healthy workplace, all successful candidates will be required to undergo respiratory fit testing in compliance with occupational health and safety standards.
Skills & Requirements •Required associate degree with a preferred bachelor's degree
•Required Licenses/Certifications
o MDL - Medical Doctor License Texas Medical Board
o RN - Lic-Registered Nurses Texas Board of Nursing or Nurse Licensure Compact
o PA - Cert-Physician Assistant Texas Medical Board
o RHIA - Cert-Reg Health Inform. Admins American Health Information Management Association (AHIMA)
o RHIT - Cert-Reg Health Inform. TECH American Health Information Management Association
o CCS - Cert-Cert Coding Specialist American Health Information Management Association
o CPC - Cert-Cert Professional Coder America Association of Professional Coders
o CCDS DOC - Cert-Cert Clinical Doc. SPCLST Association of Clinical Documentation Improvement Specialist
o CDIP - Cert-Clinical Doc. Impr. PROF American Health Information Management Association
•Preferred Pediatric experience
About Us Since 1954, Texas Children's has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children's hospital in Texas, and among the top in the nation by U.S.News & World Report as well as recognition from Houston Business Journal as one of this city's Best Places to Work for ten consecutive years.
Texas Children's comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Center for pediatric research; Texas Children's Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children's Hospital West Campus, a community hospital in suburban West Houston; and Texas Children's Hospital The Woodlands, the first hospital devoted to children's care for communities north of Houston. We have also created the nation's first HMO for children, established the largest pediatric primary care network in the country and a global health program that is channeling care to children and women all over the world. Texas Children's Hospital is also academically affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation.
To join our community of 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities.
Texas Children's is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved. Texas Children's Hospital
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