Clinical Documentation Specialist

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

📋 Description

• Perform concurrent reviews of inpatient medical records.

• Spot opportunities to enhance the quality of physician documentation.

• Facilitate modifications to clinical documentation through direct and electronic communication with physicians and healthcare team members.

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

• Engage with physicians, case managers, coders, and healthcare team members regarding inpatient clinical treatments, decisions, and diagnoses.

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

• Provide or coordinate training for internal stakeholders on compliance, coding, and clinical documentation matters.

• Consult with coders when further information or documentation is required to assign the appropriate DRG.

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

• Collect and analyze information 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 metrics.

• Prepare physician-specific data and relevant information.

• Discuss outcome information, documentation clarity, completeness, and DRG assignment with physicians.

• Coach physicians to enhance documentation reflecting service intensity and illness severity.

• Document conferences and their results.

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

• Assist with special projects and other assigned responsibilities.

• Maintain proficiency in customer service, job skills, resource management, teamwork, and innovation.

• Ensure the delivery of safe care and adherence to Memorial Hermann policies, procedures, standards, time management, supply management, productivity, and quality requirements.

• Fulfill mandatory education and skills competency requirements.

• Support departmental objectives while acting as a preceptor, mentor, and resource for less experienced staff.

• Exemplify Memorial Hermann service standards and foster compassionate, personalized experiences.

⛳️ Requirements

• Preferred candidates should be RNs with Clinical Documentation experience.

• A BSN or MSN is required for RNs.

• A Bachelor of Nursing is mandatory.

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

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

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

• Critical care/ICU nursing experience is required for consideration; ICU experience is preferred in minimum qualifications.

• Adult Med/Surg experience in an acute hospital setting may be considered.

• Exceptional observation, analytical thinking, and problem-solving abilities.

• Strong verbal and written communication skills.

• Familiarity with various areas of adult medicine.

• Capability to assess, evaluate, and educate.

• Proficiency in organization and planning.

• Computer skills including database and spreadsheet analysis, presentation software, word processing, and Internet research.

• Willingness to embrace and adapt to change.

• Ability to be flexible, self-motivated, and work independently.

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

• Strong interpersonal skills and a positive attitude are essential.

• Compliance with HIPAA and Code of Conduct policies is mandatory.

• Candidates must be eligible to work remotely for Memorial Hermann; remote positions are not available in Arizona, California, Connecticut, Florida, Maryland, Massachusetts, Missouri, New Jersey, New York, Utah, Ohio, Pennsylvania, Washington, Alabama, Mississippi, Illinois, Oregon, Arkansas, or Iowa.

• MDs or doctors are not eligible for consideration.

🏝️ Benefits

• Full-time employment opportunities.

• Support for mandatory/continuing education and skills competency.

• Opportunities for professional growth and development.

• Opportunities for preceptorship, mentorship, and resource sharing.

• A safe, caring, personalized, and efficient workplace experience.