Clinical Documentation Specialist

🔥 6 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 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 inpatient records • Use the 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 is needed to assign the correct DRG • Evaluate healthcare team documentation daily according to the designated system • 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 regulatory changes into practice • Assist with performance measures and prepare physician-specific data • Review outcome information with physicians and coach them to improve documentation accuracy • Attend hospital service line meetings and educate physicians on improvement opportunities • Comply with HIPAA and Code of Conduct policies • Assist with special projects and perform other assigned duties • Ensure safe, efficient, compliant, and quality care and support organizational goals

🎯 Requirements

• Bachelor of Nursing required • Current State of Texas license or temporary/compact license to practice professional nursing • At least five 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; adult Med/Surg experience may be considered • RN candidate preferred with clinical documentation experience • Excellent observation, analytical thinking, problem-solving, verbal, and written communication skills • Working knowledge of adult medicine • Ability to assess, evaluate, and teach • Organization and planning proficiency • Computer proficiency, including databases, spreadsheets, presentation programs, word processing, and Internet searching • Ability and willingness to seek 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 not be an MD or doctor • Must comply with HIPAA and Code of Conduct policies

🏖️ Benefits

• Mandatory/continuing education and skills competency support • Professional growth and development opportunities • Serves as preceptor, mentor and resource to less experienced staff • Remote work arrangement for eligible locations • Compassionate and personalized experiences for employees and community members