Texas Licensed Clinical Documentation Specialist

Job Summary

Working remotely on a full-time basis, a Texas Licensed Clinical Documentation Specialist will analyze medical records to enhance documentation quality, ensuring accurate representation of clinical services while collaborating with healthcare professionals and participating in educational initiatives.

Key responsibilities

• Conduct accurate and timely reviews of medical records for inpatients and manage discharged patient reconciliations
• Identify opportunities for documentation improvement through critical analysis of clinical information and physician interactions
• Provide effective communication and education to physicians regarding documentation clarifications and compliance standards

Required qualifications

• Associate's or Bachelor's degree in nursing or Health Information Management (HIM) or a related healthcare field
• Two years of related clinical experience or five years of acute care hospital inpatient coding experience
• Current RN license or RHIT, RHIA, CCS, or other relevant certifications upon hire
• Strong understanding of clinical documentation standards and compliance guidelines
• Proficient in data entry and management of CDI databases