Clinical Documentation Specialist - HIM-Clinical Doc Integrity - 002

Job Details Position: Clinical Documentation Specialist – HIM‑Clinical Doc Integrity – 002 Talent Area: Professional – Clinical Job ID: 424542 Full/Part Time: Full time Location: Houston, TX, US Department: HIM‑Clinical Doc Integrity Shift: 8a‑5p 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 and all Hospital Policies and Procedures. Maintains interaction with appropriate resources that support growth and education of the CDI team. 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. Licenses & Certifications MDL – Medical Doctor License, Texas Medical Board RN – Lic. Registered Nurse, Texas Board of Nursing or Nurse Licensure Compact PA – Cert. Physician Assistant, Texas Medical Board RHIA – Cert. Registered Health Information Administrator, American Health Information Management Association (AHIMA) RHIT – Cert. Registered Health Information Technician, AHIMA CCS – Cert. Coding Specialist, AHIMA CPC – Cert. Professional Coder, American Association of Professional Coders CCDS DOC – Cert. Clinical Documentation Specialist, Association of Clinical Documentation Improvement Specialists CDIP – Cert. Clinical Documentation Improvement Professional, AHIMA Preferred Experience Preferred Pediatric experience. About Texas Children’s Texas Children’s is a leading children’s hospital in Texas, consistently ranked among the best by U.S. News & World Report and recognized by Houston Business Journal. Equal Opportunity Employer 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. #J-18808-Ljbffr Texas Children's Hospital