Clinical Documentation Specialist - HIM Department - MD Anderson
Houston, TX
About the Job
The Clinical Documentation Specialist position in the department of HIM Administration at MD Anderson Cancer Center in Houston, TX promotes appropriate clinical documentation through collaboration with MD Anderson staff by reviewing patient documents, assessing for accuracy and educating the patient care team to ensure guidelines are met and appropriate processes are followed. They will impact the quality of clinical documentation, and in turn, effect the financial reimbursement for the institution.
The Health Information Management (HIM) Department serves a multitude of internal and external clients which include clinical and research faculty, patients and their families, staff employees, students, regulatory and accreditation agencies, third party payers and other patient representatives such as attorneys. Our team focuses on securing and maintaining health information and the management of health care information resources. Accurate, complete, secure patient information is essential to the delivery of safe, effective and reimbursable health care. We ensure that patient information meets regulatory compliance and accreditation standards.
MD Anderson offers our employees:
- Paid employee medical benefits (zero premium) starting on first day for employees who work 30 or more hours per week
- Group Dental, Vision, Life, AD&D and Disability coverage
- Paid time off (PTO) and Extended Illness Bank (EIB) paid leave accruals
- Paid institutional holidays, wellness leave, childcare leave and other paid leave programs
- Tuition Assistance Program after six months of service
- Teachers Retirement System defined-benefit pension plan and two voluntary retirement plans
- Employer paid life, AD&D and an illness-related reduced salary pay program
- Health Savings Account and Dependent Care Reimbursement flexible spending accounts
- Fertility benefits
- State of Texas longevity pay
- Extensive wellness, recognition, fitness, employee health programs and employee resource groups.
Must be flexible with time and location of work. May be asked to come into the office to work or work on the inpatient floor, shoulder or shoulder with providers.
The University of Texas MD Anderson Cancer Center is ranked the nation's top hospital for cancer care by U.S. News & World Report's "Best Hospitals." MD Anderson's mission is to eliminate cancer in Texas, the nation and the world through exceptional programs that integrate patient care, research and prevention. Our mission also includes education for undergraduate and graduate students, trainees, professionals, employees and the public.
Essential Job Functions:
Obtains and promotes appropriate clinical documentation through interaction with MD Anderson clinical staff to ensure documentation is complete, accurate and reflects the level of service rendered to patients. Performs admission reviews and concurrent reviews for specific patient populations using clinical guidelines. Reviews documentation by physicians and clinical staff as well as lab results, diagnostic information and treatment plans to assure accuracy.
Reviews files to identify documentation gaps and requests clarification from physicians and other caregivers of unclear diagnoses, patient complications, procedures and clinical documentation. Educates all members of the patient care team on documentation guidelines on an ongoing basis. Presents recommendations for process improvement opportunities regarding work flow and or policies and procedures as necessary.
EDUCATION:
Required: Bachelor's degree in Nursing or Health Information Management.
EXPERIENCE:
Required: At least five years of clinical coding or nursing experience in acute care facility. May substitute required degree with additional years of experience on a one to one basis.
Preferred: At least five years of clinical nursing experience in an acute care facility.
LICENSURE/CERTIFICATION:
Required: At least one of the following: Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or current Professional Nursing License (RN). Basic Life Support (BLS) or Cardiopulmonary Resuscitation (CPR) certification.
Preferred: Certified Clinical Documentation Improvement Practitioner (CDI) would be a plus.
OTHER: Must pass pre-employment skills test as required and administered by Human Resources.
It is the policy of The University of Texas MD Anderson Cancer Center to provide equal employment opportunity without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, disability, protected veteran status, genetic information, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. http://www.mdanderson.org/about-us/legal-and-policy/legal-statements/eeo-affirmative-action.html
Additional Information
#LI-Hybrid
The Health Information Management (HIM) Department serves a multitude of internal and external clients which include clinical and research faculty, patients and their families, staff employees, students, regulatory and accreditation agencies, third party payers and other patient representatives such as attorneys. Our team focuses on securing and maintaining health information and the management of health care information resources. Accurate, complete, secure patient information is essential to the delivery of safe, effective and reimbursable health care. We ensure that patient information meets regulatory compliance and accreditation standards.
MD Anderson offers our employees:
- Paid employee medical benefits (zero premium) starting on first day for employees who work 30 or more hours per week
- Group Dental, Vision, Life, AD&D and Disability coverage
- Paid time off (PTO) and Extended Illness Bank (EIB) paid leave accruals
- Paid institutional holidays, wellness leave, childcare leave and other paid leave programs
- Tuition Assistance Program after six months of service
- Teachers Retirement System defined-benefit pension plan and two voluntary retirement plans
- Employer paid life, AD&D and an illness-related reduced salary pay program
- Health Savings Account and Dependent Care Reimbursement flexible spending accounts
- Fertility benefits
- State of Texas longevity pay
- Extensive wellness, recognition, fitness, employee health programs and employee resource groups.
Must be flexible with time and location of work. May be asked to come into the office to work or work on the inpatient floor, shoulder or shoulder with providers.
The University of Texas MD Anderson Cancer Center is ranked the nation's top hospital for cancer care by U.S. News & World Report's "Best Hospitals." MD Anderson's mission is to eliminate cancer in Texas, the nation and the world through exceptional programs that integrate patient care, research and prevention. Our mission also includes education for undergraduate and graduate students, trainees, professionals, employees and the public.
Essential Job Functions:
Obtains and promotes appropriate clinical documentation through interaction with MD Anderson clinical staff to ensure documentation is complete, accurate and reflects the level of service rendered to patients. Performs admission reviews and concurrent reviews for specific patient populations using clinical guidelines. Reviews documentation by physicians and clinical staff as well as lab results, diagnostic information and treatment plans to assure accuracy.
Reviews files to identify documentation gaps and requests clarification from physicians and other caregivers of unclear diagnoses, patient complications, procedures and clinical documentation. Educates all members of the patient care team on documentation guidelines on an ongoing basis. Presents recommendations for process improvement opportunities regarding work flow and or policies and procedures as necessary.
EDUCATION:
Required: Bachelor's degree in Nursing or Health Information Management.
EXPERIENCE:
Required: At least five years of clinical coding or nursing experience in acute care facility. May substitute required degree with additional years of experience on a one to one basis.
Preferred: At least five years of clinical nursing experience in an acute care facility.
LICENSURE/CERTIFICATION:
Required: At least one of the following: Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or current Professional Nursing License (RN). Basic Life Support (BLS) or Cardiopulmonary Resuscitation (CPR) certification.
Preferred: Certified Clinical Documentation Improvement Practitioner (CDI) would be a plus.
OTHER: Must pass pre-employment skills test as required and administered by Human Resources.
It is the policy of The University of Texas MD Anderson Cancer Center to provide equal employment opportunity without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, disability, protected veteran status, genetic information, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. http://www.mdanderson.org/about-us/legal-and-policy/legal-statements/eeo-affirmative-action.html
Additional Information
- Requisition ID: 166916
- Employment Status: Full-Time
- Employee Status: Regular
- Work Week: Days
- Minimum Salary: US Dollar (USD) 75,000
- Midpoint Salary: US Dollar (USD) 93,500
- Maximum Salary : US Dollar (USD) 112,000
- FLSA: exempt and not eligible for overtime pay
- Fund Type: Hard
- Work Location: Hybrid Onsite/Remote
- Pivotal Position: Yes
- Referral Bonus Available?: Yes
- Relocation Assistance Available?: Yes
- Science Jobs: No
#LI-Hybrid
Source : MD Anderson