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 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 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 for correct DRG assignment • 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 rule and regulation changes into practice • Assist with performance measure development and reporting • Prepare physician-specific data and review outcomes 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 • Document conferences and results • Assist with special projects and perform other assigned duties • Ensure compliance with HIPAA, Code of Conduct, and Memorial Hermann policies • Promote professional growth and support department goals

🎯 Requirements

• Prefer an RN candidate with Clinical Documentation experience • Must be an RN with a BSN or MSN • Must have at least 5 years 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 years of inpatient, acute care at the bedside on a nursing unit • Excellent observation skills, analytical thinking, problem solving, and 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 a positive attitude • Must comply with HIPAA and Code of Conduct policies

🏖️ Benefits

• Mandatory/continuing education and skills competency support • Professional growth and development opportunities • Preceptor, mentor, and resource opportunities • Safe, caring, personalized, and efficient patient and colleague experiences