Clin Documentation Specialist
Methodist Health System
**Hours of Work :**
**Days Of Week :**
**Work Shift :**
8X5 Day (United States of America)
**Job Description :**
Your Job:
Responsible for reviewing medical records to facilitate accurate representation of severity of illness, risk of mortality, quality of care, and to ensure validity of the documented conditions. This involves extensive record analysis, interaction with healthcare providers, HIM professionals, and quality staff. Supports the mission, vision, values and strategic goals of Methodist Health System.
Your Job Requirements:
• Graduate from an accredited school of nursing or foreign medical graduate (FMG)
• RN – required (except for FMGs); CCDS, CDIP, CCS - preferred
• Basic computer skills
• Critical thinking/problem-solving skills
• Organizational, analytical, communication (written and verbal) and interpersonal skills
• Work Experience: 2 years of recent inpatient hospital experience required, preferably ICU, CCU or strong med/Surg. CDI, coding or utilization review experience is a plus.
Your Job Responsibilities:
• Successfully managing multiple priorities: query follow-up, initial chart review, concurrent chart review, MS-DRG discrepancy resolution.
• Efficient knowledge and usage of tools provided for position including computer software. Accurate input of data into the computerized system.
• Effective and appropriate communication with physicians and hospital staff.
• Perform thorough initial and concurrent medical chart reviews identifying opportunities for documentation improvement.
• Verify that all treated or monitored conditions are properly documented by the physician in the medical record using specific ICD-10 diagnostic terms.
• Verify that all documented diagnoses are clinically supported using industry-accepted diagnostic criteria.
• Formulate clinically credible, compliant queries for the medical staff to ensure accurate and complete documentation.
• Complete timely follow up on all cases; especially those with physician queries (every 1-2 days).
• Communicate with HIM coding staff to resolve MSDRG discrepancies.
• Utilize monitoring tools to track progress of the CDI program.
Methodist Health System is a faith-based organization with a mission to improve and save lives through compassionate, quality healthcare. For nearly a century, Dallas-based Methodist Health System has been a trusted choice for health and wellness. Named one of the fastest-growing health systems in America by _Modern Healthcare_ , Methodist has a network of 12 hospitals (through ownership and affiliation) with nationally recognized medical services, such as a Level I Trauma Center, multi-organ transplantation, Level III Neonatal Intensive Care, neurosurgery, robotic surgical programs, oncology, gastroenterology, and orthopedics, among others. Methodist has more than two dozen clinics located throughout the region, renowned teaching programs, innovative research, and a strong commitment to the community. Our reputation as an award-winning employer shows in the distinctions we’ve earned:
+ Magnet® designations for Methodist Dallas, Methodist Charlton, Methodist Mansfield, and Methodist Richardson Medical Centers
+ 150 Top Places to Work in Healthcare by _Becker’s Hospital Review_ , 2023
+ Top 10 Military Friendly® Employer, Gold Designation, 2023
+ Top 10 Military Spouse Friendly® Employer, 2023
Methodist Health System is a faith-based organization with a mission to improve and save lives through compassionate, quality healthcare. For nearly a century, Dallas-based Methodist Health System has been a trusted choice for health and wellness. Named one of the fastest-growing health systems in America by _Modern Healthcare_ , Methodist has a network of 12 hospitals (through ownership and affiliation) with nationally recognized medical services, such as a Level I Trauma Center, multi-organ transplantation, Level III Neonatal Intensive Care, neurosurgery, robotic surgical programs, oncology, gastroenterology, and orthopedics, among others. Methodist has more than two dozen clinics located throughout the region, renowned teaching programs, innovative research, and a strong commitment to the community. Our reputation as an award-winning employer shows in the distinctions we’ve earned:
+ Magnet® designations for Methodist Dallas, Methodist Charlton, Methodist Mansfield, and Methodist Richardson Medical Centers
+ 150 Top Places to Work in Healthcare by _Becker’s Hospital Review_ , 2023
+ Top 10 Military Friendly® Employer, Gold Designation, 2023
+ Top 10 Military Spouse Friendly® Employer, 2023
Equal Opportunity Employer
It is the policy of Methodist Health System (MHS) to select, develop, and promote employees based on individual ability and job performance. It has been, and will continue to be, the policy of MHS to provide equal employment opportunity to all people in all aspects of employer-employee relations without discrimination because of race, color, religion, national origin, age, sex, sexual orientation, gender expression, disability, marital status, genetic information or ancestry. This policy affects decisions including, but not limited to, an employee’s compensation, benefits, terms and conditions of employment, opportunities for promotion, training, development, transfer all other privileges of employment. MHS is committed to maintain a working environment free of intimidation, workplace discrimination and harassment. Retaliation or attempted retaliatory behavior that occurs as a result of an employee’s exercise of their rights under this policy or any other statutorily protected right is strictly prohibited and will be grounds for disciplinary action.
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