RN Clinical Documentation Specialist - FT Days at AdventHealth

Date Posted: 10/28/2020

Job Snapshot

  • Job Schedule
  • Location:
    Burleson, TX
  • Date Posted:
  • Job ID:
  • Job Family
    Health Information Management
  • Travel
  • Shift
    1 - Day

Job Description


RN Clinical Documentation Specialist Texas Health Huguley- operated as joint venture between Texas Health Resources and AdventHealth

Location Address: 11801 South Fwy., Burleson, TX  76028

Top Reasons to Work At Texas Health Huguley, Burleson, TX

•    Our care for patients extend to the spiritual level by praying with patients and families and providing on call, 24 hours, 7 days a week Chaplains for spiritual support.

•    Award winning facility and departments including “Great Place to Work” by Becker’s Hospital Review and Gallup.

•    Work with the latest technology and top experts including “Daisy Award” recipients while on the way to Magnet status—2020.

•    Amazing medical benefits through Aetna plus an onsite full-service fitness center.

•    Growth opportunities designed for each employee.

•    Located about 10 minutes from downtown Fort Worth and near TCU in the award-winning school district, Burleson ISD which also provides a low-cost of living.  

Work Hours:

Full Time / Days

You Will Be Responsible For:

•    Facilitates modifications to clinical documentation to ensure that appropriate documentation is received for the level of service rendered to patients with a DRG based payer.

•    Demonstrates knowledge of DRG payer issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures.

•    Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.

•    Initiates and updates the DRG worksheet to reflect any changes in status, procedures/treatments, and queries with physician to finalize diagnoses.

•    Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.

•    Conducts follow-up reviews of clinical documentation (at least every 48 hours) to ensure points of clarification have been recorded in the patient’s chart.

•    As necessary, reviews clinical issues with coding staff to assign a working DRG.

•    Ensures documentation is technically accurate on a concurrent basis that facilitates the most appropriate code assignment for principle diagnosis, principle procedure, and co-morbid conditions and complications.


What You Will Need:

•    RN, BSN preferred or AHIMA Certified Coder.

•   5 years of recent clinical experience in a hospital setting or ICD-9 coding experience.

•   Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication as well as strong interpersonal skills.

•    Working expertise in the use of Microsoft Word, Power-Point, and Excel.

•    Utilization Review and Coding experience preferred.


Job Summary:

Facilitates appropriate clinical documentation through interaction with physicians, nursing staff, other patient care givers and Health Information Management coding staff to ensure that documentation supports the level of reimbursement assigned to each case to the extent that the physician concurs.

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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