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Clinical Documentation Specialist
Memorial Hermann Health SystemClinical Documentation Specialist improving inpatient records for Memorial Hermann’s healthcare system. Supporting accurate coding, physician education, documentation compliance, and DRG accuracy remotely.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation improvement, including physician education and compliance with healthcare regulations. Proficient in analyzing medical records and collaborating with healthcare teams to enhance documentation quality and coding accuracy.
Highest-signal resume keywords
Clinical Documentation ImprovementRN License in TexasCritical Care/ICU Nursing ExperienceAnalytical Thinking and Problem-Solving SkillsCommunication Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical DocumentationMedical Record ReviewCoding ComplianceData AnalysisPatient AssessmentDocumentation EvaluationPerformance MeasurementEducation CoordinationDRG AssignmentHealthcare Regulations
Soft Skills
Interpersonal SkillsOrganization and PlanningAdaptabilitySelf-MotivationTeamwork
Tools & Technologies
Clinical Documentation SystemDatabase AnalysisSpreadsheet AnalysisPresentation ProgramsWord Processing
Certifications & Qualifications
BSN or MSN DegreeCurrent RN License
Industry Keywords
Inpatient CareAcute Hospital SettingCMS Rules and RegulationsHIPAA ComplianceHealthcare Team Collaboration
About the role
Key responsibilities & impact- Conduct concurrent reviews of inpatient medical records
- Identify opportunities to improve physician documentation quality
- Facilitate clinical documentation modifications through face-to-face and electronic interaction with physicians and healthcare team members
- Support complete, accurate, and timely coding through complete medical records
- Communicate with physicians, case managers, coders, and healthcare team members regarding inpatient clinical treatment, decisions, and diagnoses
- Use the hospital’s designated clinical documentation system to identify physician and hospital outcome opportunities
- Provide or coordinate education for internal customers on compliance, coding, and clinical documentation issues
- Consult with coders when additional information or documentation is needed to assign the correct DRG
- Evaluate medical staff and healthcare team documentation daily
- Gather and analyze information related to documentation findings and outcomes
- Develop physician education strategies and address negative documentation trends
- Identify patterns, trends, variances, and process improvement opportunities
- Research literature and incorporate CMS rules and regulations into daily practice
- Assist in developing and reporting performance measures
- Prepare physician-specific data and information
- Conference with physicians about outcome information, documentation clarity, completeness, and DRG designation
- Coach physicians to improve documentation reflecting intensity of services and severity of illness
- Document conferences and results
- Attend hospital service line meetings and educate physicians on improvement opportunities
- Assist with special projects and other assigned duties
- Maintain competency in customer service, job skills, resource management, teamwork, and innovation
- Ensure safe care and compliance with Memorial Hermann policies, procedures, standards, time management, supply management, productivity, and quality requirements
- Meet mandatory education and skills competency requirements
- Support department goals and serve as a preceptor, mentor, and resource to less experienced staff
- Model Memorial Hermann service standards and create compassionate, personalized experiences
Requirements
What you’ll need- RN candidate preferred with Clinical Documentation experience
- RN with a BSN or MSN required
- Bachelor of Nursing required
- Current State of Texas license or temporary/compact license to practice professional nursing
- At least 5 years of recent RN bedside experience in an acute hospital setting
- Five years of inpatient, acute care bedside experience on a nursing unit
- Critical care/ICU nursing experience required for consideration; ICU experience preferred in minimum qualifications
- Adult Med/Surg experience in an acute hospital setting may be considered
- Excellent observation, analytical thinking, and problem-solving skills
- Good verbal and written communication skills
- Working knowledge of many areas of adult medicine
- Ability to assess, evaluate, and teach
- Organization and planning proficiency
- Computer proficiency 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 and positive attitude
- Must comply with HIPAA and Code of Conduct policies
- Must be eligible to work remotely for Memorial Hermann; remote workers cannot be hired in Arizona, California, Connecticut, Florida, Maryland, Massachusetts, Missouri, New Jersey, New York, Utah, Ohio, Pennsylvania, Washington, Alabama, Mississippi, Illinois, Oregon, Arkansas, or Iowa
- MDs or doctors cannot be considered
Benefits
Comp & perks- Full-time employment
- Mandatory/continuing education and skills competency support
- Professional growth and development opportunities
- Preceptor, mentor, and resource opportunities
- Safe, caring, personalized, and efficient workplace experiences