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Methodist Health System

Nonprofit, faith-based integrated health system

Clinical Documentation Specialist 1

Clinical Support & Patient AdministrationPosted on Nov 11
Full-timeDallas, TX, USANo salary listedIn-person

About the Job

Requirements

  • Graduate from an accredited school of nursing.
  • A registered nurse (RN) license is required.
  • Basic computer skills are required.
  • Critical-thinking and problem-solving skills are required.
  • Organizational, analytical, writing, and interpersonal skills are required.
  • Two years of recent hospital experience are required; intensive care unit (ICU), coronary care unit (CCU), or strong medical/surgical experience is preferred.

Responsibilities

  • Manage multiple priorities, including query follow-up, initial chart review, concurrent chart review, and Medicare Severity Diagnosis-Related Group (MS-DRG) discrepancy resolution.
  • Use position tools, including computer software, efficiently and accurately enter data into the computerized system.
  • Communicate effectively and appropriately with physicians and hospital staff.
  • Perform thorough initial and concurrent medical chart reviews to identify opportunities for documentation improvement.
  • Verify that all treated or monitored conditions are properly documented by the physician in the medical record using specific International Classification of Diseases, Tenth Revision (ICD-10) diagnostic terms.
  • Verify that all documented diagnoses are clinically supported using industry-accepted diagnostic criteria.
  • Formulate clinically credible, compliant queries for medical staff to ensure accurate and complete documentation.
  • Complete timely follow-up on all cases, especially those with physician queries, every one to two days.
  • Communicate with Health Information Management (HIM) coding staff to resolve MS-DRG discrepancies.
  • Use monitoring tools to track progress of the clinical documentation improvement (CDI) program.
  • Demonstrate self-management and accountability while working remotely.

Desired Qualifications

  • A bachelor's degree is preferred.
  • Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), or Certified Coding Specialist (CCS) certification is preferred.
  • Intensive care unit (ICU), coronary care unit (CCU), or strong medical/surgical experience is preferred.
  • Clinical documentation improvement (CDI), coding, or utilization review experience is a plus.

About the Company

Methodist Health System

Nonprofit, faith-based integrated health system

Methodist Health System operates a nonprofit, faith-based network of hospitals and physician clinics across Dallas-Fort Worth, offering primary care, cardiology, orthopedics, women's health, gastroenterology, and emergency care. Its network includes several medical centers and Methodist Medical Group's clinics. What sets Methodist Health System apart is its covenant tie to the North Texas Conference of the United Methodist Church and its sizable charity care commitment. The goal is to improve and save lives through compassionate, quality healthcare.

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