Clinical Documentation Specialist

🔥 18 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 review of inpatient medical records to identify opportunities to improve physician documentation • Facilitate clinical documentation modifications through interaction with physicians and healthcare team members • Communicate with physicians, case managers, coders, and other healthcare team members to support comprehensive medical record documentation • Use the hospital’s designated clinical documentation system to identify documentation and hospital outcome opportunities • Provide or coordinate education 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 with performance measure development and reporting • Prepare physician-specific data and review outcome information with key physicians • Coach physicians to improve documentation accuracy regarding 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 adhere to Memorial Hermann policies, procedures, and standards • Promote professional growth and development and serve as preceptor, mentor, and resource to less experienced staff

🎯 Requirements

• Prefer an RN candidate with Clinical Documentation experience • Must be an RN with a BSN or MSN • Must have at least 5yrs of recent RN bedside experience in an acute hospital setting • Must have critical care, ICU nursing experience to be considered • Bachelor of Nursing required • Current State of Texas license or temporary/compact license to practice professional nursing • Five (5) years of inpatient, acute care at the bedside on a nursing unit; ICU experience preferred • Excellent observation skills, analytical thinking, problem solving, verbal and written communication • 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 • Please Note: We cannot consider MDs or doctors for this position

🏖️ Benefits

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