Clinical Documentation & Integrity Specialist

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

📋 Description

• Perform concurrent assessments of inpatient medical records to identify areas for enhancing physician documentation.

• Encourage modifications to clinical documentation through collaboration with physicians and healthcare team members.

• Ensure comprehensive medical record documentation supports complete, accurate, and timely coding.

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

• Utilize the hospital's designated clinical documentation system to pinpoint documentation and hospital outcome opportunities.

• Educate internal stakeholders on compliance, coding, and issues related to clinical documentation.

• Collaborate with coders when additional information or documentation is required to assign the appropriate DRG.

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

• Collect and analyze information regarding documentation findings and outcomes.

• Create physician education strategies to encourage complete and accurate documentation.

• Recognize patterns, trends, variances, and opportunities for process improvement.

• Research literature and integrate CMS rules and regulations into daily operations.

• Assist in developing and reporting performance metrics and physician-specific data.

• Confer with physicians about clarity, completeness, outcomes, and DRG designation of documentation.

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

• Participate in hospital service line meetings and inform physicians about improvement opportunities.

• Adhere to HIPAA and Code of Conduct policies.

• Support special projects and other assigned tasks.

• Ensure safe care and compliance with Memorial Hermann policies, procedures, and standards.

• Foster professional growth and development while serving as a preceptor, mentor, and resource.

• Deliver safe, caring, personalized, and efficient experiences to patients and colleagues.

⛳️ Requirements

• Must possess an RN with a BSN or MSN.

• Bachelor of Nursing is required.

• Current State of Texas license or temporary/compact license to practice professional nursing is essential.

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

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

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

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

• Clinical Documentation experience is preferred.

• Familiarity with various areas of adult medicine is essential.

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

• Capability to assess, evaluate, and instruct.

• Proficiency in organization and planning is necessary.

• Computer literacy, including database and spreadsheet analysis, presentation software, word processing, and Internet research is required.

• Willingness to pursue and embrace change.

• Must possess adaptability, flexibility, self-motivation, and the ability to work independently.

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

• A professional team-player attitude and strong interpersonal skills are essential.

• Must not be an MD or doctor.

• Remote employees cannot be hired in Arizona, California, Connecticut, Maryland, Massachusetts, Missouri, New Jersey, New York, Utah, Ohio, Pennsylvania, Washington, Alabama, Mississippi, Illinois, Oregon, Arkansas, or Iowa.

🏝️ Benefits

• Mandatory/continuing education and skills competency support.

• Opportunities for professional growth and development.

• Preceptor, mentor, and resource opportunities available.

• Positive working environment.

• Full-time employment.