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Clinical Documentation Improvement Specialist - Clinical Documentation Improvement (Full Time D

Methodist Hospital
Methodist Healthcare System
Type Full time Posted 7/10/2014
Salary - n/a - Starts ASAP
TX - Texas (All) - San Antonio Referral 02531-52444    

Excellence isn’t just a word at Methodist Healthcare System. It’s what drives our staff each day and what makes us the most preferred healthcare provider for San Antonio and its surrounding counties. As San Antonio grows, so do we. In fact, we’re looking to expand our teams with exceptional professionals like you as we build for our future.

Methodist Healthcare System is proud to call San Antonio its home, the popular “Alamo City” because of two world famous attractions, The Alamo and the River Walk. The city is well-diversified and offers a resilient local economy and a good place to start a new career or raise a family due to the low cost of living in terms of housing and agriculture. If you are seeking a challenging and exciting career opportunity in a great city, join us in leading our vision to make San Antonio the healthiest city in the nation. Join Methodist Excellence today, it starts with you!

Responsible for improving the overall integrity of medical records documentation. Facilitates modifications to medical record documentation through appropriate interactions with physicians, nursing staff, other patient caregivers, and medical records coding staff. Advocates for appropriate patient classification relative to the resources consumed and the level of service provided. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Follows coding guidelines and all internal hospital policies and procedures to ensure compliance with clinical documentation.


  • Conducts initial concurrent review process for all selected admissions to initiate tracking process, documenting findings on DRG worksheets, and identification of other key pathway or quality indicators as appropriate; acts as liaison for documentation efficiencies with Health Information Management, Case Management, Ancillary Departments, Physicians, Nursing and Administration.
  • Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures; improves the overall quality and completeness of clinical documentation by performing record reviews using clinical documentation guidelines which then supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.
  • Interacts and communicates with Physician staff daily as needed – educating them in the process of clarifying documentation in the medical record; conducts follow up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
  • Maintains the DRG Worksheet to include abstraction of patient clinical findings relevant to assign an ongoing working DRG, Physician Documentation Request/interactions and visit frequency; in collaboration with the physician and coder, identifies and records principal and secondary diagnosis, principal procedures, and assigns a working DRG.
  • Identifies needs to clarify documentation in records and initiates communication with physician by utilizing the appropriate “query” tools in order to capture the documentation in the medical record that supports patient’s severity of illness; performs a thorough chart review to identify co morbidities/complications; documents all known MCC’s and CC’s appropriately on the DRG worksheet.
  • Demonstrates an understanding of the importance of and makes an effort to capture ALL secondary diagnoses (for profiling purposes), including those that do not directly affect the DRG assignment; reviews coder feedback on completed worksheets and individual internal tracking system reports as a means of continuous self evaluation; discusses any issues or concerns with the Director.


  • Registered Nurse (BSN preferred) with current Texas license; three years recent clinical experience in a hospital setting (preferred) with at least 2 years in management capacity (preferred). Utilization Review or coding experience preferred.
  • Licensed as a Registered Nurse in the State of Texas

To Apply:
Please submit your resume to Pamela.McDonald2@MHShealth.com or apply online at: https://hca.taleo.net/careersection/jobdetail.ftl?job=02531-52444&lang=en&sns_id=gmail

Methodist Healthcare System is an Equal Opportunity Employer.

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Contact Information

Methodist Healthcare System
7700 Floyd Curl Drive
San Antonio,TX