Clinical Documentation Specialist

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

📋 Description

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

• Drive modifications in clinical documentation by engaging with physicians and members of the healthcare team.

• Liaise with physicians, case managers, coders, and other healthcare professionals to foster thorough medical record documentation.

• Utilize the hospital’s clinical documentation system to discover opportunities for physician and hospital outcomes.

• Educate internal stakeholders on compliance, coding, and clinical documentation matters.

• Collaborate with coders when further information or documentation is required for accurate DRG assignment.

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

• Collect and analyze data related to documentation findings and outcomes.

• Formulate educational strategies for physicians and address adverse documentation trends.

• Identify patterns, trends, discrepancies, and opportunities for process enhancements.

• Research relevant literature and integrate changes from CMS rules and regulations into practice.

• Assist with the development and reporting of performance measures.

• Prepare physician-specific data and review results with key physicians.

• Guide physicians to enhance the accuracy of documentation concerning service intensity and illness severity.

• Participate in hospital service line meetings and educate physicians on potential improvement avenues.

• Document conferences and their outcomes.

• Support special projects and carry out other assigned responsibilities.

• Ensure adherence to HIPAA, the Code of Conduct, and Memorial Hermann policies.

• Foster professional growth while supporting departmental objectives.

⛳️ Requirements

• RN candidates with Clinical Documentation experience are preferred.

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

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

• Critical care or ICU nursing experience is essential for consideration.

• A Bachelor of Nursing degree is mandatory.

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

• Five years of inpatient, acute care experience at the bedside in a nursing unit is required.

• Exceptional observation skills, analytical thinking, problem-solving abilities, and strong verbal and written communication are necessary.

• Familiarity with various aspects of adult medicine is important.

• Ability to assess, evaluate, and provide education is essential.

• Strong organizational and planning skills are required.

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

• A readiness to seek out and embrace change is crucial.

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

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

• A professional team player with excellent interpersonal skills and a positive demeanor is required.

• Must adhere to HIPAA and Code of Conduct policies.

🏝️ Benefits

• Support for mandatory/continuing education and skills competency.

• Opportunities for professional growth and development.

• Availability of preceptor, mentor, and resource opportunities.

• Commitment to providing safe, caring, personalized, and efficient experiences for patients and colleagues.