Clinical Documentation Specialist

🕒 September 2

🤠 Texas – Remote

🤠 Texas – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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Memorial Hermann Health System

WebsiteLinkedInAll Job Openings

10,000+ employees

⚕️ Healthcare Insurance

🏥 Healthcare

🧘 Wellness

💰 $5M Grant on 2022-08

Healthcare Insurance • Healthcare • Wellness

Memorial Hermann Health System is a comprehensive healthcare organization that provides a wide range of medical services, including cancer care, cardiovascular services, emergency and trauma care, women’s health, and surgical services. With the largest network of emergency centers in Greater Houston, it focuses on delivering advanced healthcare and wellness programs tailored to individual needs. Memorial Hermann is committed to advancing health equity and enhancing community health through its various medical facilities and services.

📋 Description

• Conduct concurrent reviews of inpatient medical records to identify opportunities to improve physician documentation quality • Facilitate clinical documentation modifications through face-to-face and electronic interactions with physicians and healthcare team members • Support complete, accurate, and timely coding through comprehensive medical record documentation • Communicate with physicians, case managers, coders, and healthcare team members regarding clinical treatment, decisions, and diagnoses • Use the hospital’s designated clinical documentation system to identify physician and hospital outcome opportunities • Educate internal customers on compliance, coding, and clinical documentation issues • Consult with coders when additional information or documentation is needed to assign the correct DRG • Evaluate medical staff and healthcare team documentation daily • Gather and analyze information related to documentation findings and outcomes • Develop physician education strategies and address negative documentation trends • Identify documentation patterns, trends, variances, and process improvement opportunities • Research literature and incorporate CMS rules and regulatory changes into daily practice • Assist with performance measure development and reporting • Prepare physician-specific data and present outcome information to medical staff and departments • Conference with physicians regarding documentation clarity, completeness, and correct DRG designation • Coach physicians to improve documentation reflecting intensity of services and severity of illness • Document conferences and results • Attend hospital service line meetings and educate physicians on improvement opportunities • Comply with HIPAA and Code of Conduct policies • Assist with special projects and other assigned duties • Ensure safe care and comply with Memorial Hermann policies, procedures, and standards • Promote professional growth and support department goals • Serve as a preceptor, mentor, and resource to less experienced staff

🎯 Requirements

• RN with a BSN or MSN • Bachelor of Nursing required • Current State of Texas license or temporary/compact license to practice professional nursing • At least 5 years of recent RN bedside experience in an acute hospital setting • Five years of inpatient, acute care bedside experience on a nursing unit • Critical care/ICU nursing experience required for consideration; ICU experience preferred in the minimum qualifications • Prefer clinical documentation experience • Excellent observation, analytical thinking, problem-solving, verbal, and written communication skills • Working knowledge of many areas of adult medicine • Ability to assess, evaluate, and teach • Organization and planning proficiency • Computer proficiency, including database and spreadsheet analysis, presentation programs, word processing, and Internet searching • Ability and willingness to seek out and accept change • Adaptability, flexibility, self-motivation, and ability to work independently • Knowledge of federal, state, and private payer regulations preferred • Professional team player with strong interpersonal skills and a positive attitude • Must not be an MD or doctor • Remote workers 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

• Full-time employment • Professional growth and development through mandatory/continuing education and skills competency • Preceptor, mentor, and resource opportunities • Employee-focused workplace emphasizing safety, compassion, personalization, and efficiency