Clinical Documentation & Integrity Specialist

🔥 0 minutes ago

🤠 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 • Facilitate clinical documentation modifications through interaction with physicians and healthcare team members • Support complete, accurate, and timely coding through comprehensive medical record documentation • Communicate with physicians, case managers, coders, and other healthcare team members • Use the hospital’s designated clinical documentation system to identify documentation 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 to promote complete and accurate documentation • Identify patterns, trends, variances, and process improvement opportunities • Research literature and incorporate CMS rules and regulations into daily practice • Assist with developing and reporting performance measures and physician-specific data • Conference with physicians about documentation clarity, completeness, outcomes, and DRG designation • Coach physicians to improve documentation reflecting intensity of services and severity of illness • 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 adherence to Memorial Hermann policies, procedures, and standards • Promote professional growth and development and serve as a preceptor, mentor, and resource • Provide safe, caring, personalized, and efficient experiences to patients and colleagues

🎯 Requirements

• Must be an 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 five (5) years of recent RN bedside experience in an acute hospital setting • Five (5) years of inpatient, acute care bedside experience on a nursing unit • Critical care/ICU nursing experience required for consideration • Pediatric/Neonatal experience may be considered in lieu of CDI or ICU experience • Clinical Documentation experience preferred • Working knowledge of many areas of adult medicine • Excellent observation, analytical thinking, problem-solving, verbal, and written communication skills • 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 attitude and strong interpersonal skills • 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

• Mandatory/continuing education and skills competency support • Professional growth and development opportunities • Preceptor, mentor, and resource opportunities • Positive working environment • Full-time employment