Methodist Hospitals · 4 hours ago
CLINICAL DOCUMENT SPECIALIST
Merrillville, IN
Full-time
Onsite
Mid, Senior Level
3+ years expMethodist Hospitals is seeking a Clinical Document Specialist to facilitate and obtain complete medical record documentation. The role involves ensuring accurate clinical documentation at the point of service, collaborating with coders, and educating the patient care team on documentation guidelines.
Health CareHospitalMedical
Responsibilities
Responsible for facilitating concurrent documentation of the medical record to achieve accurate inpatient coding and legitimate DRG assignment for billing integrity
Reviews all provider documentation as necessary to ensure complete and accurate documentation
Collaborates with HIM Coders to ensure that the clinical information used in measuring and reporting outcomes is complete and accurate and reimbursement is received for the level of services rendered to patients with DRG-based payers
Participates in education of members of the patient care team on documentation guidelines as guided by department leadership
Collect and analyze data to provide reports and make recommendations
Completes admission reviews of patient records within 24-48 hours of admission for specified patient population to evaluate documentation and generate the working DRG
Conducts concurrent follow-up reviews of records as necessary, not to exceed 4 days from prior review
Update notes and revise working DRG based on new documentation
Electronically query physicians/other providers regarding missing, unclear, or conflicting medical record documentation and obtains additional documentation within the medical record when needed
Document all reviews in the CDI application to facilitate tracking, data collection, and communication with coders and department leaders
Take all necessary action to resolve physician queries prior to patient discharge
Contribute to and participate in physician, nursing, and other ancillary staff education documentation requirements
Utilize EHR Clinical Documentation Improvement process flow tools to collect data to support reporting of required indicators - Number of reviews per day/patient - Query generation - Query completion to include outcome - Current and expected DRG with weight change - APR-DRG SOI score improvement
Make recommendations for change processes required to capture needed documentation, such as note template and query content redesign
Qualification
Required
Registered Health Information Technologist/Registered Health Information Administrator
Excellent communication skills
Ability to work independently and in a team environment
Self-starter, professional courtesy, positive attitude
Demonstrates knowledge of procedures for protecting and maintaining security, confidentiality, and integrity of employee, patient and family, organizational, or other medical information. Understands and supports the commitment of Methodist Hospitals in adhering to federal, state, and local laws, rules, and regulations governing ethical business practices for healthcare providers
An Associate's Degree from a recognized college or university in Nursing and a current Registered Nurse licensure in the State of Indiana, OR a Bachelor's Degree from a recognized college or university in health records management or a closely related field and RHIA
Associates Nursing Required
Bachelors Health Information Required
Minimum 2 years inpatient hospital coding experience
2 years Healthcare/Medical - Health Information Systems/Technology/MIS Required
RHIA - Registered Health Info Administrator
RHIT - Registered Health Info Technician
Licensed Registered Nurse
Preferred
Minimum 3 years' experience in Clinical documentation Improvement (Preferred), hospital inpatient quality chart review or Case Management
Company
Methodist Hospitals
Methodist Hospitals is an acute care community hospital that is expertise in rendering a wide range of medical services to various patients.
1001-5000 employees
H1B Sponsorship
Methodist Hospitals 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 (1)
2023 (1)
2022 (1)
2021 (1)
Funding
Current Stage
Late StageLeadership Team
Lauren P. Trumbo, CPA
System Chief Financial Officer/Vice President of Finance
Matthew Doyle
Chief Financial Officer
Recent News
2024-05-05
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