Clinical Documentation Specialist

At Houston Methodist, we are dedicated to providing exceptional patient care and promoting a culture of innovation and advancement. As a Clinical Documentation Specialist, you will play a crucial role in ensuring the accuracy and integrity of patient medical records. Your attention to detail and expertise in clinical documentation will directly impact the quality of care our patients receive. We are seeking a highly skilled and motivated individual with a strong understanding of medical terminology and coding, as well as proficiency in electronic medical record systems. If you are passionate about improving healthcare through effective documentation, we invite you to apply for this exciting opportunity at Houston Methodist.

1. Accurately review and analyze patient medical records to ensure completeness, accuracy, and compliance with regulatory standards.
2. Identify and report any discrepancies or deficiencies in clinical documentation to the appropriate healthcare providers for clarification and correction.
3. Collaborate with physicians, nurses, and other healthcare professionals to obtain missing or incomplete information in medical records.
4. Utilize knowledge of medical terminology, anatomy, and coding guidelines to accurately code and sequence diagnoses and procedures in medical records.
5. Stay up-to-date on changes and updates in coding and documentation guidelines and regulations.
6. Provide education and training to healthcare providers on proper documentation practices to promote accurate and complete medical records.
7. Utilize electronic medical record systems to document and track changes and updates to patient medical records.
8. Collaborate with the revenue cycle team to ensure accurate billing and appropriate reimbursement.
9. Ensure compliance with all regulatory requirements, including CMS and Joint Commission standards.
10. Maintain confidentiality and security of patient information in accordance with HIPAA regulations.
11. Participate in quality improvement initiatives related to clinical documentation and coding.
12. Act as a resource for healthcare providers for any questions or concerns related to clinical documentation.
13. Communicate effectively with interdisciplinary team members to promote a culture of collaboration and teamwork.
14. Uphold and promote the mission, values, and standards of Houston Methodist in all aspects of job performance.

According to JobzMall, the average salary range for a Clinical Documentation Specialist is between $53,000 to $87,000 per year. However, this can vary depending on factors such as location, experience, and employer. Some Clinical Documentation Specialists may also receive benefits such as health insurance and retirement plans.

Houston Methodist Hospital is the flagship quaternary care hospital of Houston Methodist academic medical center. Located in the Texas Medical Center in Houston, Texas, Houston Methodist Hospital was established in 1919 during the height of the Spanish influenza epidemic as an outreach ministry of Methodist Episcopal Church. Houston Methodist comprises eight hospitals, an academic institute, a primary care group, and more than 300 locations throughout greater Houston. The hospital has consistently ranked as "One of America's Best Hospitals" according to U.S. News & World Report. The hospital has earned worldwide recognition in multiple specialties including cardiovascular surgery, cancer, epilepsy treatment and organ transplantation. Houston Methodist System changed its official name to Houston Methodist in 2013.