Texas Licensed Clinical Documentation Specialist

Job Summary

To enhance the quality of clinical documentation, the full-time Texas Licensed Clinical Documentation Specialist will conduct concurrent reviews of inpatient medical records, collaborating with physicians and healthcare teams to ensure accurate coding and comprehensive documentation, all while working remotely.

Key responsibilities

• Communicates with physicians and healthcare team members to facilitate comprehensive medical record documentation
• Utilizes the clinical documentation system to identify opportunities for improvement in physician and hospital outcomes
• Provides education on compliance, coding, and clinical documentation issues to internal customers

Required qualifications

• Bachelor of Nursing (BSN) required; MSN preferred
• Current Texas nursing license (RN) required
• Minimum of 5 years of recent RN bedside experience in an acute hospital setting, with critical care or ICU experience preferred
• Strong knowledge of adult medicine and familiarity with federal, state, and private payer regulations
• Proficiency in computer usage, including database and spreadsheet analysis