RN Clinical Documentation Specialist - HIM, Health Information Management

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