Clinical Documentation Integrity Specialist

This is a fully remote position, open to applicants in Texas.

📋 Description

• Perform concurrent reviews of inpatient medical records to pinpoint areas for enhancing physician documentation.

• Facilitate adjustments in clinical documentation by engaging with physicians and members of the healthcare team.

• Collaborate with physicians, case managers, coders, and other healthcare team members to ensure thorough and precise inpatient documentation.

• Utilize the hospital’s clinical documentation system to detect documentation opportunities and assess outcomes.

• Provide or coordinate training on compliance, coding, and issues related to clinical documentation.

• Consult with coders when additional information is needed to assign the appropriate DRG.

• Assess healthcare team documentation daily according to the specified clinical documentation system.

• Collect and analyze documentation findings and their outcomes.

• Create educational strategies for physicians and mentor them to enhance documentation accuracy.

• Identify trends, discrepancies, and opportunities for process improvement.

• Research literature and integrate CMS regulations and guidelines into practice.

• Assist in the development and reporting of performance measures.

• Examine physician outcome data along with the clarity, completeness, and DRG assignments of documentation.

• Participate in hospital service-line meetings and educate physicians about potential improvement opportunities.

• Adhere to HIPAA and Code of Conduct policies.

• Contribute to special projects and carry out other assigned responsibilities.

• Advocate for the safety of patients, staff, and visitors while supporting departmental objectives.

• Fulfill mandatory education and competency requirements; serve as a preceptor, mentor, and resource for less experienced staff.

⛳️ Requirements

• Bachelor of Nursing is required.

• Must possess an RN with either a BSN or MSN.

• Current Texas state license or a temporary/compact license to practice professional nursing is necessary.

• A minimum of 5 years of recent RN bedside experience in an acute hospital environment.

• Five years of inpatient acute-care bedside experience within a nursing unit.

• Critical care/ICU nursing experience is required for consideration.

• Pediatric/Neonatal experience may be accepted in place of CDI or ICU experience.

• Clinical Documentation experience is preferred.

• Strong observation, analytical thinking, and problem-solving abilities.

• Effective verbal and written communication skills.

• Familiarity with various aspects of adult medicine.

• Capability to assess, evaluate, and teach.

• Proficient in organization and planning.

• Competent in computer skills, including database and spreadsheet analysis, presentation software, word processing, and internet research.

• Willingness to embrace and adapt to change.

• Flexibility, self-motivation, and the ability to work independently.

• Knowledge of federal, state, and private payer regulations is preferred.

• A professional team player with strong interpersonal skills and a positive attitude.

• Please Note: MDs or doctors are not eligible for consideration.

• Must be eligible for remote work; Memorial Hermann does not hire remote employees in Arizona, California, Connecticut, Maryland, Massachusetts, Missouri, New Jersey, New York, Utah, Ohio, Pennsylvania, Washington, Alabama, Mississippi, Illinois, Oregon, Arkansas, or Iowa.

🏝️ Benefits

• Full-time employment.

• Support for mandatory/continuing education and skills competency.

• Opportunities for professional growth and development.

• Opportunities to serve as a preceptor, mentor, and resource.

• A compassionate and personalized work environment.