- Certified Registered Health Information Administrator (RHIA), or Technician (RHIT), or an associate degree in a health care related discipline with Certified Coding Specialist (CCS) certification, and a minimum of 3 years medical coding experience.
- Registered nurse (or medical school graduate) with a minimum of 3 years inpatient clinical experience, advanced clinical expertise and an extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting.
- Review inpatient admissions in real-time to identify and resolve any missing or incomplete documentation.
- Collaborate effectively with providers, case managers, coders, and other healthcare team members to ensure comprehensive health record documentation reflects accurate clinical information.
- Utilize the hospital's designated clinical documentation system to review records and find opportunities for clarification.
- Communicate with physicians to address missing or unclear documentation through queries and ensure proper documentation of responses.
- Provide education on clinical documentation opportunities to staff and physicians for ongoing improvement.
- Assist coding professionals in obtaining necessary information for accurate coded data assignment.
- Stay updated on coding guidelines and relevant regulatory updates to ensure compliance.
- Bachelor of Science in Nursing (BSN)
- CCDS or CDIP Certification
- One year CDI experience
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Clinical Documentation Specialist - Galveston, United States - UTMB Health
Description
Clinical Documentation Specialist (Remote/Texas Resident) - Clinical Data Management
Company: UTMB Health
Location: Galveston, Texas, United States
Minimum Qualifications:
Or
Licenses, Registrations, or Certifications Required:
RN current license or RHIA/RHIT/CCS (medical school graduates are exempt from this MQ)
And
Must acquire CCDS or CDIP certification within 3 years of hire
Job Summary:
Role Overview: As a Clinical Documentation Specialist, you'll play a vital role in enhancing the quality and accuracy of medical record documentation through close collaboration with physicians, care team members, and coding staff within the hospital.
Responsibilities:
Preferred Qualifications:
Requirements:
Demonstrate strong observation, analytical, problem-solving, verbal, and written communication skills.
Salary Range:
Competitive salary based on experience.
Work Schedule:
Remote position for Texas residents.
Monday to Friday, 8am to 5pm, with occasional flexibility as needed.
Equal Employment Opportunity:
UTMB Health is an equal opportunity employer that values diversity and inclusion. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other protected status. UTMB Health is committed to affirmative action and diversity in its workforce.
