Clinical Documentation 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 modifications in clinical documentation by collaborating with physicians and members of the healthcare team.

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

• Utilize the designated clinical documentation system of the hospital to identify opportunities for improved documentation and hospital outcomes.

• Provide or coordinate training on compliance, coding, and clinical documentation topics.

• Consult with coders when additional information or documentation is required to accurately assign the correct DRG.

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

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

• Create strategies for physician education and address negative trends in documentation.

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

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

• Assist in the development and reporting of performance measures.

• Prepare physician-specific data and discuss outcome information with key physicians.

• Mentor physicians to enhance documentation accuracy concerning intensity of services and severity of illness.

• Attend service line meetings at the hospital and educate physicians on opportunities for improvement.

• Adhere to HIPAA regulations and the Code of Conduct policies.

• Support special projects and other assigned responsibilities.

• Ensure safe patient care and comply with Memorial Hermann's policies, procedures, and standards.

• Encourage professional growth and development, serving as a preceptor, mentor, and resource for less experienced staff.

⛳️ Requirements

• Preference given to RN candidates with Clinical Documentation experience.

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

• At least 5 years of recent bedside RN experience in an acute hospital setting is required.

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

• A Bachelor of Nursing degree is mandatory.

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

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

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

• Working knowledge across various areas of adult medicine is important.

• Ability to assess, evaluate, and teach effectively.

• Proficiency in organization and planning is required.

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

• Openness to seek out and accept changes is necessary.

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

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

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

• Please note: MDs or doctors cannot be considered for this position.

🏝️ Benefits

• Mandatory and continuing education, along with skills competency development.

• Opportunities for professional growth and development.

• Roles as a preceptor, mentor, and resource available.

• A team-oriented working atmosphere.

• Full-time employment offered.