Texas Licensed Clinical Documentation Specialist

Job Summary

Working remotely, the full-time Texas Licensed Clinical Documentation Specialist will analyze health records, apply coding standards, and provide education to healthcare providers while ensuring documentation integrity and compliance.

Key responsibilities

• Collaborates with healthcare team members to identify and assign principal and secondary diagnoses, ensuring accurate MS-DRG assignments
• Conducts concurrent reviews of inpatient admissions and documents findings using 3M CDIS software
• Facilitates documentation improvement by communicating with physicians and healthcare professionals to clarify and enhance medical records

Required qualifications

• Degree in nursing or a Master's Degree in a Healthcare/Medical related field from an accredited institution, or completion of an accredited Health Information Management coding program
• For RNs: Minimum of three years of clinical experience in an acute care setting; for HIM professionals: at least two years of inpatient coding experience
• Certification as a Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) is required
• Expert knowledge of ICD-10 and CPT coding principles, medical terminology, and clinical auditing processes
• Proficiency in MS Office software, including Word, Excel, and PowerPoint