Texas Licensed Clinical Documentation Specialist

Job Summary

To enhance clinical documentation accuracy in a long-term acute care setting, the full-time Texas Licensed Clinical Documentation Specialist will evaluate patient medical records, conduct concurrent and retrospective reviews, and collaborate with healthcare providers to ensure compliance with documentation standards.

Key responsibilities

• Conduct daily concurrent reviews of inpatient medical records for accuracy and completeness
• Initiate compliant queries to physicians for vague or ambiguous documentation and follow up on responses
• Provide education and support to clinical staff on documentation requirements and coding specificity

Required qualifications

• Graduate of an accredited School of Nursing (BSN preferred) or Health Information Management program
• Active Registered Nurse (RN) license, or RHIA/RHIT certification; CCDS or CDIP preferred
• Minimum of 3-5 years of acute care clinical nursing or CDS/coding experience
• Strong knowledge of ICD-10-CM coding conventions and CMS guidelines
• Proficiency with Electronic Health Record (EHR) systems and CDI tracking software