Texas Licensed Clinical Documentation Specialist

Job Summary

To enhance clinical documentation accuracy, the remote Texas Licensed Clinical Documentation Specialist will review patient records, communicate with healthcare teams, and initiate provider queries while ensuring compliance with documentation standards.

Key responsibilities

• Review patient records concurrently to ensure accurate reflection of services and acuity in medical documentation
• Communicate effectively with physicians and multidisciplinary teams to educate on documentation opportunities and ensure completeness
• Initiate and follow up on physician queries for clarification and maintain updated CDI/DRG worksheets reflecting patient status changes

Required qualifications

• 3 years of acute care hospital nursing experience, preferably in critical care, or 5 years 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 maintain expert knowledge of CDI practices and performance
• Experience in a remote work environment is preferred