Texas Licensed Clinical Document Specialist

Job Summary

To enhance clinical documentation quality, the remote Texas Licensed Clinical Document Specialist will facilitate concurrent reviews of patient records, communicate with healthcare teams, and initiate provider queries for documentation clarification.

Key responsibilities

• Review patient records to ensure accurate reflection of services and acuity in clinical documentation
• Communicate with physicians and multidisciplinary teams to educate on documentation practices and opportunities
• Initiate and follow up on physician queries for clarification and maintain updated CDI/DRG worksheets

Required qualifications

• 3 years of acute care hospital nursing experience, preferably in critical care, or 5 years of nursing experience including 3 years in critical care
• Current RN license and certification in Clinical Documentation (CCDS or CDIP) within 6 months of hire
• Experience working in a Clinical Documentation Integrity program
• Ability to maintain expert knowledge of CDI practices and performance
• Experience in a remote work environment is preferred