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Houston Methodist · 1 day ago

Clinical Documentation Specialist

Los Angeles, CA

Full-time

Onsite

Entry Level

1+ years exp

Houston Methodist is seeking a Clinical Documentation Specialist to lead efforts in improving the quality and accuracy of clinical documentation. The role involves conducting reviews, providing education on documentation opportunities, and ensuring appropriate reimbursement for services rendered.

Health CareMedical

Growth Opportunities

H1B Sponsor Likely

Responsibilities

Improves the overall quality, completeness and accuracy of clinical documentation by performing open record reviews using clinical documentation guidelines

Seeks additional information regarding clinical condition from appropriate clinical personnel and follows up as necessary

Tracks responses and trends completion of DRG/Documentation worksheets as pertinent to scope of department

Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart

Requests clarification and/or correction from physicians for unclear diagnoses, complications, procedures, and clinical information

Helps identify appropriate ICD10 codes for diagnoses or procedures related to projects or studies being conducted as needed

Promotes clarification to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients

Identifies diagnoses and procedures performed and comorbidities and complications

Impacts discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, conferring with physician to finalize diagnosis as necessary

Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies

Qualification

CCDS certificationCDIP certificationCCS certificationClinical documentation knowledgeAnalytical thinkingCustomer service focusProblem solvingVerbal communicationWritten communication

Required

Medical School graduate where Western Medicine is practiced

CCDS - Clinical Documentation Specialists (ACDIS) or

CDIP - Certified Documentation Integrity Practitioner (AHIMA) or

CCS - Certified Coding Specialist (AHIMA)

Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations

Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security

Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles

Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures

Demonstrates accountability and professional development

Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication

Regular significant contacts with other personnel throughout the institution (including but not limited to – physicians and their staff, mid-level providers, mid-level staff, coders, Case Managers). Contacts may be in person, by telephone, or through correspondence. Requires assertiveness while being even tempered, with a pleasing personality and the ability to communicate easily with others

Preferred

One year of clinical experience preferred

Company

Houston Methodist

Glassdoor4.3

Houston Methodist is one of the nation’s leading health systems and academic medical centers.

Founded in 1919

Houston, Texas, USA

10001+ employees

http://www.houstonmethodist.org/

H1B Sponsorship

Houston Methodist has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (15)

2024 (11)

2023 (14)

2022 (12)

2021 (10)

2020 (10)