Texas Licensed Clinical Documentation Specialist

Job Summary

To enhance clinical documentation quality, the remote Texas Licensed Clinical Documentation Specialist will review patient records, communicate with healthcare teams, and initiate provider queries, ensuring accurate representation of services and care levels.

Key responsibilities

• Review patient records concurrently to ensure accurate documentation of services and acuity of care
• Communicate effectively with physicians and multidisciplinary teams to promote complete documentation of diagnoses and treatments
• Initiate physician queries for clarification and follow up to ensure documentation accuracy prior to discharge

Required qualifications

• 3 years of acute care hospital nursing experience, preferably in critical care, or 5 years of nursing experience with 3 years in critical care
• Current RN license and certification in Clinical Documentation (CCDS or CDIP) obtained within 6 months of hire
• Experience working in a Clinical Documentation Integrity program
• Ability to work effectively in a remote environment
• Bachelor's Degree in nursing (BSN) preferred