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RN Clinical Documentation Specialist - HIM, Health Information Management

St Luke's Health - Patients Medical Center Pasadena, Texas

The posted compensation range of $33.00 - $52.80 /hour is a reasonable estimate that extends from the lowest to the highest pay CommonSpirit in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. CommonSpirit may ultimately pay more or less than the posted range as permitted by law.

Requisition ID 2023-303298 Employment Type Full Time Department Health Information Management Hours/Pay Period 80 Shift Day Weekly Schedule Day Remote No Category Medical Coding

Patients Medical Center (PMC) provides inpatient and outpatient medical and surgical services to residents of Pasadena, Deer Park, La Porte, Baytown, and Clear Lake. The facility includes 53 medical/surgical beds, eight ICU beds and three endoscopy rooms, and offers a range of primary and specialized services—wound care, general surgery, gastroenterology, occupational health, heart and vascular, women’s services, diagnostic imaging, outpatient rehab services, and sleep disorders.


Job Responsibilities for RN Clinical Documentation Specialist Health Information Management

Facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the CDMP process is a key role.

  • Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program  (CDMP) documentation strategies
  • Accurate and timely record review
  • Recognize opportunities for documentation improvement
  • Initiates CDMP severity Worksheet for inpatients
  • Formulate clinically credible documentation clarifications
  • Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety
  • Effective and appropriate communication with physicians
  • Timely follow-up on all cases and resolution of those with clinical documentation clarifications
  • Participate in Task Force Meetings
  • Manage multiple priorities
  • Communicates with HIM staff and resolves discrepancies
  • Accurate input of data into CDMP Trak


Required Qualifications

Education and Licensure

*High School Diploma/GED
*Registered Nurse (RN)
Minimum Experience
*Five (5) years of adult acute care experience in med/surg, critical care, emergency room, or PACU
Minimum Knowledge, Skills, and Abilities
*Ability to learn/develop the skills necessary to perform CDMP
*Organizational, analytical, writing, and interpersonal skills
*Dependable, self-directed and pleasant
*Critical thinking, problem-solving, and deductive reasoning skills
*Knowledge of Pathophysiology and Disease Process
*Basic Computer skills – familiarity with Windows-based software programs
*Knowledge of the regulatory environment

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CommonSpirit Health™ is an Equal Opportunity/Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law. For more information about your EEO rights as an applicant, please click here.

CommonSpirit Health™ will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c). External hires must pass a post-offer, pre-employment background check/drug screen. Qualified applicants with an arrest and/or conviction will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, ban the box laws, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances. If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (415) 438-5575 and let us know the nature of your request. We will only respond to messages left that involve a request for a reasonable accommodation in the application process. We will accommodate the needs of any qualified candidate who requests a reasonable accommodation under the Americans with Disabilities Act (ADA). CommonSpirit Health™ participates in E-Verify.