Healthcare Documentation Specialist

4 weeks ago


Dallas, Texas, United States Children's Health Full time
Company Overview

At Children's Health, our mission is to make a meaningful difference in the lives of children and their families. As a leading pediatric healthcare provider, we strive to deliver exceptional patient care and outcomes while fostering a culture of compassion, innovation, and collaboration.

Estimated Salary

Ranges from $65,000 to $85,000 per annum, depending on qualifications and experience.

Job Description

The Clinical Documentation Specialist plays a vital role in ensuring the accuracy and completeness of patient documentation, which is essential for reimbursement, quality metrics, and informed decision-making. This position involves working closely with physicians, nursing staff, and other caregivers to improve documentation quality, facilitate concurrent modifications, and support timely and accurate reporting.

Responsibilities
  1. Interprets and implements APR-DRG and Medicare-based reimbursement requirements to ensure accurate and compliant documentation.
  2. Conducts thorough reviews of patient records to evaluate documentation integrity, identify opportunities for improvement, and implement changes to enhance reimbursement and quality metrics.
  3. Collaborates with coding professionals to ensure accuracy and completeness of diagnostic and procedure data, and facilitates APR-DRG assignment, risk of mortality, and severity of illness assessment.
  4. Provides education and training to physicians and clinicians on the importance of accurate and complete documentation, regulatory compliance, and best practices.
  5. Partners with coding professionals to ensure accuracy and completeness of supporting documentation and to determine appropriate APR-DRG assignment.
  6. Queries physicians regarding missing, unclear, or conflicting health record documentation to ensure accurate and complete records.
Required Skills and Qualifications

This role requires a minimum of 4 years of experience in Health Information Management, Healthcare Administration, Healthcare Operations, Coding, Nursing, Case Management, or experience as a Physician. A Bachelor's degree or equivalent experience is also required. Preferred qualifications include a Licensed Medical Doctor, Licensed RN, RRT, PT, or Registered Health Information Management Technician/ Administrator.

Benefits

We offer a comprehensive benefits package, including employee portion of medical plan premiums covered after 3 years, 4%-10% employee savings plan match based on tenure, Paid Parental Leave (up to 12 weeks), Caregiver Leave, Adoption and surrogacy reimbursement, and more. Children's Health is an equal opportunity employer and welcomes, values, and respects the beliefs, identities, and experiences of our patients and colleagues.

A Place Where You Belong

We put our people first and are committed to delivering culturally effective care, creating meaningful partnerships in the communities we serve, and equipping and developing our team members to make Children's Health a place where everyone can contribute.


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