Clinical Documentation Specialist - Outpatient

Job Description

We are searching for an Outpatient Clinical Documentation Specialist -- someone who works well in a fast-paced setting. In this position, you will be responsible for activities which improve the accuracy of facility Outpatient clinical documentation and charging through retrospective chart review and claims audits. Additionally, this includes education with the clinical departments and root cause correction to support accurate charging and coding in compliance with Hospital/Health System policies. The OP CDS assist clinical areas to effectively document services and understand the relationship of documentation, medical necessity, and charging for the services provided in accordance with Hospital/Health System policies and procedures.

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Job Duties & Responsibilities
• Chart audits and review of clinical workflows to evaluate opportunities to implement charge capture best practices.
• Conducts chart reviews of assigned clinical departments to regularly review the documentation and charge accuracy and to integrate into educational sessions with the clinical departments and medical staff.
• Conduct auditing and monitoring of assigned areas.
• Performs review of accounts identified as potentially missing charges and conducts additional research to help resolve the areas of opportunity and identify the root cause of the issues causing the missed charges.
• Maintains current knowledge of applicable regulatory standards, which may impact utilization of processes and systems.
• Lead process improvement and education of clinical, CDI, and coding teams.
• Reporting and analysis of data for discussion with clinical or financial teams.
• Strong, in-depth knowledge of CPT and HCPCS coding methodologies, as well as an understanding of CMS compliance regulations as they relate to hospital outpatient coding.

Skills & Requirements
• Required associate degree with a preferred bachelor's degree
• Required Licenses/Certifications (one of the following)
o MDL - Medical Doctor License by the Texas Medical Board
o RN - Lic-Registered Nurses by the Texas Board of Nursing or Nurse Licensure Compact
o PA - Cert-Physician Assistant by the Texas Medical Board
o RHIA - Cert-Reg Health Inform. Admins by the American Health Information Management Association (AHIMA)
o RHIT - Cert-Reg Health Inform. TECH by the American Health Information Management Association
o CPC - Cert-Cert Professional Coder by the America Academy of Professional Coders
o COC - Certified Outpatient Coder by the America Academy of Professional Coders
o CCS - Cert-Cert Coding Specialist by the American Health Information Management Association
o CDEO Certified Documentation Expert Outpatient by the America Academy of Professional Coders
o CCDS DOC - Cert-Cert Clinical Doc. SPCLST by the Association of Clinical Documentation Improvement Specialist
o CDIP - Cert-Clinical Doc. Impr. PROF by the American Health Information Management Association
• Required 5 years healthcare related experience with preferred pediatric experience in hospital outpatient charging, coding, and/or revenue capture functions and knowledge of APC and OPPS reimbursement structures

About Us

Since 1954, Texas Children's has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children's hospital in Texas, and among the top in the nation by U.S. News & World Report as well as recognition from Houston Business Journal as one of this city's Best Places to Work for ten consecutive years.

Texas Children's comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Tower for pediatric research; Texas Children's Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children's Hospital West Campus, a community hospital in suburban West Houston; Texas Children's Hospital The Woodlands, the first hospital devoted to children's care for communities north of Houston; and Texas Children's Hospital North Austin, the new state-of-the-art facility providing world-class pediatric and maternal care to Austin and Central Texas families. We have also created Texas Children's Health Plan, the nation's first HMO focused on children; Texas Children's Pediatrics, the largest pediatric primary care network in the country; Texas Children's Urgent Care clinics that specialize in after-hours care tailored specifically for children; and a global health program that is channeling care to children and women all over the world. Texas Children's Hospital is affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation.

To join our community of 15,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities.

Texas Children's is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.