Clinical Documentation Specialist


Houston, TX

What you'll be doing

Promotes clarification to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients. Demonstrates the knowledge of DRG payor issues, optimization strategies, clinical documentation requirements and referral policies and procedures. Improves that overall quality and completeness of clinical documentation by performing record reviews using clinical documentation guidelines. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical outcomes. Process discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, conferring with physician to finalize diagnosis. Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies. Conducts follow-up reviews of clinical documentation to ensure points of clarification recorded in the patient chart. Reviews clinical issues with the coding staff assign a working DRG and/or clarification of documentation. Tracks response to clinical documentation specialist and trends completion of DRG/documentation worksheets. Participates in patient care conferences to identify needs for clinical documentation, as appropriate. Assists with special projects as needed and performs other job-related duties as assigned.

What your background should be

At least five years of recent clinical experience in a hospital setting. Utilization review or coding experience is preferred. Registered nurse with current Texas licensure, BSN preferred. The candidate must adhere to all safety regulations. Excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication required.

Required Schooling / Training

Not specified

Who is the client company

Concern about healthcare services.
If you are interested in this position, send your resume to