Texas Licensed Clinical Documentation Specialist

Job Summary

To support healthcare documentation integrity, the full-time Texas Licensed Clinical Documentation Specialist will work remotely, applying clinical knowledge to analyze health records, optimize physician documentation, and provide education to healthcare staff.

Key responsibilities:

• Collaborates with healthcare professionals to identify principal and secondary diagnoses, assigning MS-DRGs or APR-DRGs for identified populations
• Conducts concurrent reviews on selected inpatient admissions and documents findings using 3M CDIS software
• Facilitates documentation clarification and provides in-services to physicians and ancillary staff while maintaining patient confidentiality

Required qualifications:

• Degree in nursing, a Master's degree in a healthcare-related field, or graduation from an accredited Health Information Management coding program
• Three years of clinical experience in an acute care setting for RNs or two years of inpatient coding experience for HIM professionals
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) certification is required
• Expert knowledge of medical terminology, anatomy, physiology, and ICD-10/CPT coding principles
• Proficiency in MS Office software, including Word, Excel, and PowerPoint