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, interact with physicians and healthcare teams, and facilitate modifications to ensure accurate coding, all while working remotely.

Key responsibilities

• Communicates with healthcare team members to ensure comprehensive medical record documentation reflects clinical treatment and decisions
• Utilizes the clinical documentation system to identify improvement opportunities in physician and hospital outcomes
• Develops and delivers education strategies for physicians to promote accurate clinical documentation and correct negative trends

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
• Minimum of 5 years of recent RN bedside experience in an acute hospital setting, with critical care or ICU experience preferred
• Proficiency in clinical documentation systems and knowledge of federal, state, and private payer regulations
• Strong analytical skills and ability to communicate effectively with healthcare professionals