Clinical Documentation Integrity Specialist

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

📋 Description

• Perform concurrent reviews of inpatient medical records to uncover opportunities for enhancing physician documentation.

• Facilitate modifications in clinical documentation through collaboration with physicians and healthcare team members.

• Ensure complete, accurate, and timely coding by utilizing comprehensive medical records.

• Communicate effectively with physicians, case managers, coders, and other members of the healthcare team.

• Utilize the hospital's designated clinical documentation system to identify opportunities for physician and hospital outcomes.

• Provide or coordinate education on compliance, coding, and clinical documentation matters.

• Consult with coders when further documentation is necessary to assign the correct Diagnosis-Related Group (DRG).

• Review medical staff and healthcare team documentation on a daily basis.

• Collect and analyze documentation findings and outcome data.

• Develop educational strategies for physicians and address trends in negative documentation.

• Identify patterns, trends, variances, and opportunities for process improvements.

• Conduct research on literature and integrate CMS rules and regulations into daily operations.

• Assist with performance metrics and prepare data specific to physicians.

• Engage in discussions with physicians about clarity, completeness, and accurate DRG assignment in documentation.

• Coach physicians to enhance documentation that accurately reflects the intensity of services and severity of illness.

• Attend hospital service line meetings and provide education on improvement opportunities for physicians.

• Adhere to HIPAA and Code of Conduct policies.

• Contribute to special projects as needed.

• Ensure safe patient care while complying with Memorial Hermann policies, procedures, standards, budget, productivity, and quality requirements.

• Meet mandatory educational and competency requirements while supporting departmental goals.

• Act as a preceptor, mentor, and resource for less experienced staff.

• Perform additional duties as assigned.

⛳️ Requirements

• MDs or doctors are not eligible for consideration.

• RN with a BSN or MSN is required.

• A Bachelor of Nursing degree is mandatory.

• Must possess a current State of Texas license or a temporary/compact license for professional nursing practice.

• At least five (5) years of recent RN bedside experience in an acute hospital environment is necessary.

• Five (5) years of inpatient, acute care experience at the bedside on a nursing unit is required.

• Critical care/ICU nursing experience is necessary for consideration, with ICU experience preferred among minimum qualifications.

• Strong observation, analytical thinking, problem-solving, verbal, and written communication skills are essential.

• A working knowledge of various areas of adult medicine is required.

• Capability to assess, evaluate, and teach is needed.

• Proficiency in organizational and planning skills is necessary.

• Competence in computer usage, including database and spreadsheet analysis, presentation software, word processing, and internet research, is required.

• Willingness to seek out and adapt to change is essential.

• Adaptability, flexibility, self-motivation, and the ability to work autonomously are important.

• Familiarity with federal, state, and private payer regulations is preferred.

• A professional team player with excellent interpersonal skills and a positive attitude is necessary.

🏝️ Benefits

• Mandatory continuing education and skills competency development.

• Opportunities for professional growth and development.

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

• Safe, caring, personalized, and efficient experiences for both patients and colleagues.