Clinical Documentation 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 • Identify opportunities to improve physician documentation quality • Facilitate clinical documentation modifications through face-to-face and electronic interaction with physicians and healthcare team members • Support complete, accurate, and timely coding through complete medical records • Communicate with physicians, case managers, coders, and healthcare team members regarding inpatient clinical treatment, decisions, and diagnoses • Use the hospital’s designated clinical documentation system to identify physician and hospital outcome opportunities • Provide or coordinate education for 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 patterns, trends, variances, and process improvement opportunities • Research literature and incorporate CMS rules and regulations into daily practice • Assist in developing and reporting performance measures • Prepare physician-specific data and information • Conference with physicians about outcome information, documentation clarity, completeness, and 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 • Assist with special projects and other assigned duties • Maintain competency in customer service, job skills, resource management, teamwork, and innovation • Ensure safe care and compliance with Memorial Hermann policies, procedures, standards, time management, supply management, productivity, and quality requirements • Meet mandatory education and skills competency requirements • Support department goals and serve as a preceptor, mentor, and resource to less experienced staff • Model Memorial Hermann service standards and create compassionate, personalized experiences

🎯 Requirements

• RN candidate preferred with Clinical Documentation experience • RN with a BSN or MSN required • 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 minimum qualifications • Adult Med/Surg experience in an acute hospital setting may be considered • Excellent observation, analytical thinking, and problem-solving skills • Good 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 • Strong interpersonal skills and positive attitude • Must comply with HIPAA and Code of Conduct policies • Must be eligible to work remotely for Memorial Hermann; remote workers cannot be hired 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 cannot be considered

🏖️ Benefits

• Full-time employment • Mandatory/continuing education and skills competency support • Professional growth and development opportunities • Preceptor, mentor, and resource opportunities • Safe, caring, personalized, and efficient workplace experiences