Clinical Documentation Specialist

Role Overview

• Responsible for concurrent review of inpatient medical records
• Identify opportunities for improving the quality of physician documentation
• Facilitate modifications to clinical documentation through interaction with physicians and healthcare team
• Achieve complete medical records to support accurate coding
• Communicate with case managers, coders, and healthcare team members
• Provide or coordinate education related to compliance and clinical documentation issues
• Gather and analyze information pertinent to documentation findings
• Develop physician education strategies for improving documentation

Requirements

• Must be an RN with a BSN or MSN
• At least 5 years of recent RN bedside experience in an acute hospital setting
• Critical care, ICU nursing experience preferred
• Current State of Texas license or temporary/compact license to practice professional nursing
• Excellent observation skills, analytical thinking, and problem solving
• Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching
• Strong interpersonal skills and positive attitude

Benefits

• Medical, dental, and vision coverage
• 401(k) retirement plan with employer matching
• Paid time off including vacation and sick days
• Opportunities for professional development and continuing education
• Supportive work environment that prioritizes employee well-being