Texas Licensed Clinical Documentation Specialist

Job Summary

To enhance the quality and accuracy of medical record documentation, the remote Texas Licensed Clinical Documentation Specialist will collaborate with healthcare providers and coding staff while ensuring clinical documentation aligns with coding guidelines and accurately reflects patient care.

Key responsibilities:

• Review inpatient admissions to identify and clarify missing or incomplete documentation
• Collaborate with healthcare team members to facilitate comprehensive health record documentation
• Utilize clinical documentation systems to conduct reviews and ensure accurate representation of patient status

Required qualifications:

• Certified Registered Health Information Administrator (RHIA), Technician (RHIT), or associate degree with Certified Coding Specialist (CCS) certification
• Registered nurse or medical school graduate with a minimum of 3 years of inpatient clinical experience
• Current RN license or RHIA/RHIT/CCS certification
• Must obtain CCDS or CDIP certification within 3 years of hire
• Preferred: One year of CDI experience for nurse candidates