Clinical Documentation Specialist; Remote

At Memorial Hermann, we pursue a common goal of delivering high quality, efficient care while creating exceptional experiences for every member of our community. When we say every member of our community, that includes our employees. We know that when our employees feel cared for, heard and valued, they are inspired to create moments that exceed expectations, while prioritizing safety, compassion, personalization and efficiency.

If you want to advance your career and contribute to our vision of creating healthier communities, now and for generations to come, we want you to be a part of our team.

This position is responsible for concurrent review of inpatient medical records in order to identify opportunities for improving the quality of physician documentation. This position facilitates modifications to clinical documentation through concurrent interaction with physicians (face-to-face and electronically) and other members of the health care team. The goal of this position is to achieve a complete medical record in order to support complete, accurate and timely coding.

• Arizona
• California
• Connecticut
• Maryland
• Massachusetts
• Missouri
• New Jersey
• New York
• Utah
• Ohio
• Pennsylvania
• Washington
• Alabama
• Mississippi
• Illinois
• Oregon
• Arkansas
• Iowa

We cannot consider MDs or doctors for this position.

• 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
• Prefer critical care, ICU nursing experience

• Education: Bachelor of Nursing required.
• Licenses/Certifications: Current State of Texas license or temporary/compact license to practice professional nursing
• Experience / Knowledge /
  
  Skills:
  
  
  • Five (5) years of inpatient, acute care at the bedside on a nursing unit; ICU experience preferred
  • Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
  • Possesses a working knowledge of many areas of adult medicine
  • Able 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
  • Demonstrates adaptability, flexibility, and self-motivation, and an ability to work independently
  • Knowledge of federal, state and private payer regulations preferred
  • Professional, team player, able to communicate well with others
  • Strong interpersonal skills and positive attitude
  • Regular, significant contact with other personnel throughout and outside Memorial Hermann;
    Contact may be in person, by telephone, or through correspondence

• Communicates with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients.
• Utilizes the hospital’s designated clinical documentation system to identify opportunities for physician and hospital outcomes.
• Provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG.
• Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team in accordance with the hospital’s designated clinical documentation system.
• Gathers and analyzes information pertinent to documentation findings and outcomes.
• Contributes to a positive working environment and performs other duties as assigned or directed to enhance the overall efforts of the organization.
• Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends.
• Identifies patterns, trends variances and opportunities to improve documentation review and process.
• Researches literature and stays abreast of CMS rules and regulations, incorporating changes to daily practice for overall…