Clinical Documentation Spec - Health Information Management - Business Services Group

Position: Clinical Documentation Spec - Health Information Management - Business Services Group

Job ID: 157760

Location: US-TX-Houston


Talent Area: Professional - Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a -5p Monday - Friday

About Texas Children's Hospital

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 Center 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; and Texas Children’s Hospital The Woodlands, the first hospital devoted to children’s care for communities north of Houston. We have also created the nation’s first HMO for children, established the largest pediatric primary care network in the country and a global health program that is channeling care to children and women all over the world. Texas Children’s Hospital is also academically affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation.   To join our community of 14,000+ dedicated team members, visit for career opportunities. You can also learn more about our amazing culture at   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.    


We are searching for a Clinical Documentation Specialist— someone who works well in a fast-paced setting. In this position, you will function as the coordinator/educator for the Inpatient Documentation Improvement Program. You will facilitate the improvement of the overall quality and completeness of clinical documentation in patient records through extensive interaction with physicians, nursing staff, other patient caregivers, and HIM coding staff.


 Think you’ve got what it takes?

Responsibilities :


  • Ensure that medical record documentation provides an accurate representation of the patient’s clinical care, diagnosis, severity, and expected risk of mortality sufficient to support APR-DRG assignment
  • Review selected patients with coders and other team members for opportunities in improvement in documentation
  • Utilize CDI software to gather and analyze information pertinent to documentation findings and outcomes
  • Demonstrate an understanding of complications, co-morbidities, the severity of illness, risk of mortality, case mix, secondary diagnosis, the impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team
  • Participate in departmental and hospital committees and assigned task force groups
  • Provide consultation services to supervisory personnel regarding employees with unsatisfactory work performance or other issues of concern
  • Monitor paper and online files for compliance with program standards and intervene as necessary



  • An associate degree, bachelor’s degree preferred
  • Licensed Medical Doctor from the Texas Medical Board or
  • Licensed Registered Nurse from the Texas Board of Nursing or
  • Certified Physician Assistant from the Texas Medical Board or
  • Certified Registered Health Information Administrator from the American Health Information Management Association or
  • Certified Registered Health Information Technician from the American Health Information Management Association or
  • Certified Coding Specialist from the American Health Information Management Association or
  • Certified Professional Coder or Coder Apprentice from the American Academy of Professional Coders or
  • Certified Clinical Documentation Specialist from the Association of Clinical Documentation Improvement Specialist or
  • Certified Documentation Improvement Practitioner from the American Health Information Management Association
  • Pediatric experience is preferred

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