Texas Licensed Clinical Documentation Specialist

Job Summary

To enhance the quality of physician documentation, the full-time Texas Licensed Clinical Documentation Specialist will conduct concurrent reviews of inpatient medical records, interact with healthcare teams, and facilitate modifications to ensure complete and accurate coding in a remote setting.

Key responsibilities

• Communicates with physicians and healthcare team members to improve medical record documentation reflecting clinical treatment and decisions
• Utilizes clinical documentation systems to identify opportunities for enhancing physician and hospital outcomes
• Provides education on compliance, coding, and clinical documentation issues, acting as a consultant to coders for accurate DRG assignment

Required qualifications

• Bachelor of Science in Nursing (BSN) or Master of Science in Nursing (MSN) required
• Current State of Texas nursing license or temporary/compact license
• Five years of recent RN bedside experience in an acute hospital setting, with critical care or ICU experience preferred
• Proficiency in computer usage, including database and spreadsheet analysis
• Knowledge of federal, state, and private payer regulations preferred