Clinical Documentation Integrity Specialist

🔥 12 hours 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 complete medical records • Communicate with physicians, case managers, coders, and other healthcare team members • Use the hospital’s designated clinical documentation system to identify physician and hospital outcome opportunities • Provide or coordinate education on compliance, coding, and clinical documentation issues • Consult with coders when additional documentation is needed to assign the correct DRG • Evaluate medical staff and healthcare team documentation daily • Gather and analyze documentation findings and outcome information • Develop physician education strategies and address negative documentation trends • Identify patterns, trends, variances, and process improvement opportunities • Research literature and incorporate CMS rules and regulations into daily practice • Assist with performance measures and prepare physician-specific data • Conference with physicians regarding documentation clarity, completeness, and correct 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 • Ensure safe care and adherence to Memorial Hermann policies, procedures, standards, budget, productivity, and quality requirements • Meet mandatory education and competency requirements and support department goals • Serve as preceptor, mentor, and resource to less experienced staff • Perform other duties as assigned

🎯 Requirements

• MDs or doctors cannot be considered • 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 at the bedside on a nursing unit • Critical care/ICU nursing experience required for consideration; ICU experience preferred in the minimum qualifications • 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 • Proficiency in organization and planning • Proficiency in computer usage, 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 positive attitude

🏖️ Benefits

• Mandatory/continuing education and skills competency • Professional growth and development opportunities • Preceptor, mentor, and resource opportunities • Safe, caring, personalized, and efficient experiences for patients and colleagues