MD Anderson Cancer Center Clinical Documentation Specialist in Houston, Texas

Clinical Documentation Specialist

Location: United States, Texas, Houston, Houston (TX Med Ctr) at

Nursing at

VP Clinical Support Svcs Area 710378

Requisition #: 117089

The mission of The University of Texas M. D. Anderson Cancer Center is to eliminate cancer in Texas, the nation, and the world through outstanding programs that integrate patient care, research and prevention, and through education for undergraduate and graduate students, trainees, professionals, employees and the public.

Salary range: min-$68,800 mid-$86,000 max-$103,200


The primary purpose of the Clinical Documentation Specialist position is to promote appropriate clinical documentation through collaboration with MD Anderson staff by reviewing patient documents, assessing for accuracy and educating the patient care team to ensure guidelines are met and appropriate process is followed; impacts the quality of clinical documentation and in turn effects the financial reimbursement for the institution.


Key Function #1

Obtains and promotes appropriate clinical documentation through interaction with MD Anderson clinical staff to improve overall quality and completeness of physician clinical documentation; review chart and complete work-sheet with specified time frame after admission; request clarification from physicians and other caregivers face to face or via query notice of unclear diagnosis, patient complications, procedures and clinical documentation to clarify information, obtain needed documentation, and present opportunities to educate regarding the significance of appropriate documentation needed to support clinical severity of the patient.

Key Function #2

Identify the most appropriate principal diagnosis and CC’s to accurately reflect severity of illness in compliance with government regulations and coding guidelines Conducts timely follow-up reviews of clinical documentation to ensure issues clarified with the physician have been recorded in the medical record; updates work-sheets at least every 48 hours or as indicated; Reviews and verifies clinical issues with coding staff to ensure appropriate DRG and completeness of supporting diagnosis.

Key Function #3

Educates all members of the patient care team on documentation guidelines on an ongoing basis. Presents recommendations for process improvement opportunities regarding work flow and or policies and procedures as necessary. Express ideas clearly and concisely in groups and one to one conversations; and create an environment with open channels of communication.

Other duties as assigned


Analytical Thinking - Gather relevant information systematically; break down problems into simple components; make sound decisions.

Innovative Thinking - Approach problems with curiosity and open-mindedness; offer new ideas, solutions and/or options.

Self-Adaptability - Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.

Service Orientation

Provide service to our customers, including patients, patient caregivers, referring physicians and each other, in a reliable, responsive, safe, friendly and courteous manner.

• Promotes inclusiveness and collegiality by demonstrating respect and professionalism to others at all times

• Models safe, ethical behavior, mitigating risk to the institution through sound business practices, and adherence to MD Anderson’s Standards of Conduct, institutional policies and procedures

•Meets time and attendance expectations and respondsto requests in a timely manner, communicating expectations for procedures, service arrival, or project deliverables to patients and coworkers

• Admits when wrong, apologize and take steps to resolve a situation to help to patients and coworkers before being asked



Deadlines (Frequent 34-66%)

Traveling (Frequent 34-66%)

Physical Proximity (Constant 67-100%)

Sedentary Environment (Frequent 34-66%)


Keyboarding (Constant 67-100%)

Sitting (Frequent 34-66%)

Standing (Frequent 34-66%)

Walking (Frequent 34-66%)

Carrying (Frequent 34-66%) (Weight 10-20 lbs)

Lifting (Frequent 34-66%) (Weight 10-20 lbs)

Pushing/Pulling (Frequent 34-66%) (Weight 10-20 lbs)


Attention to detail


Working Alone

Interpersonal Skills

Written Communication


Required: Bachelor's degree in Nursing or Health Information Management.

EXPERIENCE: Five years of clinical coding or nursing experience in acute care facility. May substitute required degree with additional years of experience on a one to one basis.

One of the following: Certified Coding Specialist (CCS) from the American Health Information Management Association (AHIMA). Registered Health Information Technician (RHIT) from the American Health Information Management Association (AHIMA). Registered Health Information Administrator (RHIA) from the American Health Information Management Association (AHIMA).

Current State of Texas Professional Nursing License (RN). Must pass pre-employment skills test as required and administered by Human Resources.

It is the policy of The University of Texas MD Anderson Cancer Center to provide equal employment opportunity without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, disability, protected veteran status, genetic information, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law.