MD Anderson Cancer Center Clinical Documentation Specialist - HIM Administration in Houston, Texas
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.
MD Anderson offers our employees:
Paid employee medical benefits (zero premium) starting on first day
Minimum 24.5 days paid leave in first year (PTO & holidays)
Tuition Assistance Program
Teacher's Retirement System defined-benefit pension plan
Employer paid short-term disability, life & accidental death insurance
State of Texas longevity pay
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.
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.
Required : Bachelor's degree in Nursing or Health Information Management.
Required: At least f ive 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: Five years of clinical documentation experience in acute care facility.
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 Practioner (CDI).
American Heart Association Basic Life Support (BLS), ACLS (Advanced Cardiac Life Support) or PALS (Pediatric Advanced Life Support) certification as required by patient care area.
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.
Requisition ID: 152027
Employment Status: Full-Time
Employee Status: Regular
Work Week: Days
Minimum Salary: US Dollar (USD) 71,000
Midpoint Salary: US Dollar (USD) 89,000
Maximum Salary : US Dollar (USD) 107,000
FLSA: exempt and not eligible for overtime pay
Fund Type: Hard
Work Location: Onsite
Pivotal Position: Yes
Referral Bonus Available?: No
Relocation Assistance Available?: Yes
Science Jobs: No