Clinical Documentation & Integrity Specialist

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

📋 Description

• Perform ongoing reviews of inpatient medical records to uncover areas for enhancing physician documentation.

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

• Ensure complete, accurate, and timely coding along with appropriate DRG assignments.

• Engage with physicians, case managers, coders, and other healthcare professionals regarding medical record documentation.

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

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

• Assess documentation from medical staff and healthcare teams.

• Collect and analyze documentation findings and results.

• Formulate physician education strategies aimed at enhancing documentation completeness and accuracy.

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

• Research literature and stay updated on CMS rules and regulations.

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

• Consult with and mentor physicians about documentation clarity, completeness, service intensity, illness severity, and DRG classification.

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

• Adhere to HIPAA regulations and Code of Conduct policies.

• Assist with special projects and other assigned responsibilities.

• Foster safe, compassionate, personalized, and efficient experiences for patients and colleagues.

⛳️ Requirements

• RN with a BSN or MSN degree.

• Bachelor of Nursing is mandatory.

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

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

• Five years of inpatient, acute care bedside experience on a nursing unit.

• Critical care and ICU nursing experience is required for eligibility.

• Exceptional observational, analytical thinking, problem-solving, and verbal and written communication skills.

• Working knowledge across various areas of adult medicine.

• Capability to assess, evaluate, and instruct.

• Strong organizational and planning skills.

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

• Willingness to seek and embrace change.

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

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

• Professional, team-oriented, and possess strong interpersonal skills.

• Candidates must not be MDs or doctors.

🏝️ Benefits

• Mandatory and ongoing education along with skills competency development.

• Opportunities for professional growth and development.

• Preceptor, mentor, and resource support for less experienced staff.