Clinical Documentation Integrity Specialist (Remote)

About the Role

This position is responsible for concurrent review of inpatient medical records to identify opportunities for improving the quality of physician documentation. The role facilitates modifications to clinical documentation through concurrent interaction with physicians (face-to-face and electronically) and other members of the healthcare team. The goal is to achieve a complete medical record that supports accurate and timely coding.

Responsibilities

• Communicates with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation reflecting clinical treatment, decisions, and diagnoses for inpatients.
• Utilizes the hospital’s designated clinical documentation system to identify opportunities for improving physician and hospital outcomes.
• Provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues; acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG.
• Evaluates documentation by the medical staff and healthcare team daily in accordance with the hospital’s designated clinical documentation system.
• Gathers and analyzes information pertinent to documentation findings and outcomes.
• Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends.
• Identifies patterns, trends, variances, and opportunities to improve documentation review and processes.
• Researches literature and stays abreast of CMS rules and regulations, incorporating changes into daily practice for overall documentation enhancement.
• Assists in the development and reporting of performance measures to the medical staff and other departments; prepares physician-specific data information.
• Conferences with key physicians to review outcome information (including physician profile data if relevant) related to documentation clarity, completeness, and correct DRG designation. Coaches physicians to improve documentation accuracy.
• Documents conference outcomes and results.
• Attends hospital service line meetings, reviews outcome information, and educates physicians on service-line-specific improvement opportunities.
• Complies with HIPAA and Code of Conduct policies.
• Assists with special projects as needed.
• Demonstrates competency in customer service, job skills, resource management, teamwork, and innovation.
• Ensures safe care to patients, staff, and visitors by adhering to all Memorial Hermann policies, procedures, and standards within budgetary specifications.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency.
• Models Memorial Hermann’s service standards by providing safe, caring, personalized, and efficient experiences to patients and colleagues.
• Other duties as assigned.

Requirements

• Must be a Registered Nurse (RN) with a BSN or MSN.
• Current State of Texas license or temporary/compact license to practice professional nursing.
• Five (5) years of recent RN bedside experience in an acute hospital setting; ICU experience preferred.
• Critical care or ICU nursing experience required.
• Excellent observation skills, analytical thinking, problem-solving, and strong verbal and written communication skills.
• Working knowledge of many areas of adult medicine.
• Ability to assess, evaluate, and teach.
• Proficiency in organization, planning, and computer usage, including database and spreadsheet analysis, presentation programs, word processing, and Internet searching.
• Ability and willingness to seek out and accept change; adaptability, flexibility, self-motivation, and ability to work independently.
• Knowledge of federal, state, and private payer regulations preferred.
• Strong interpersonal skills, positive attitude, and ability to work well with others.

Memorial Hermann cannot hire remote workers in the following states: Arizona, California, Connecticut, Maryland, Massachusetts, Missouri, New Jersey, New York, Utah, Ohio, Pennsylvania, Washington, Alabama, Mississippi, Illinois, Oregon, Arkansas, or Iowa.

MDs or doctors are not eligible for this position.