Clinical Documentation Specialist - Remote | WFH - Get It Recruit - Healthcare
Houston, TX 77024
About the Job
Overview:
We are currently seeking a motivated and experienced Remote Clinical Documentation Improvement Specialist to join our dynamic team. The successful candidate will be responsible for concurrent review of inpatient medical records to enhance the quality of physician documentation. This role involves collaborating with physicians and healthcare team members to ensure accurate and comprehensive medical records, ultimately supporting efficient coding processes.
Responsibilities:
Collaborate with physicians, case managers, coders, and other healthcare professionals to improve clinical documentation for inpatient care.
Utilize designated clinical documentation systems to identify opportunities for enhanced documentation and improved outcomes.
Provide education to internal stakeholders on compliance, coding, and clinical documentation best practices.
Evaluate documentation by medical staff and healthcare team members, ensuring alignment with organizational standards.
Analyze documentation findings and outcomes, identifying opportunities for process improvement.
Develop physician education strategies to promote accurate and complete clinical documentation.
Stay updated on CMS rules and regulations, incorporating changes into daily practice to enhance documentation processes.
Confer with physicians to review documentation clarity, completeness, and accuracy, providing coaching as needed.
Attend service line meetings, reviewing outcome information and educating physicians on improvement opportunities.
Ensure compliance with HIPAA and organizational policies and procedures.
Assist with special projects and perform other duties as assigned.
Qualifications:
Bachelor of Nursing required; BSN preferred.
Current State of Texas license or temporary/compact license to practice professional nursing.
Minimum of five years of inpatient acute care nursing experience, preferably in ICU.
Strong analytical, communication, and interpersonal skills.
Proficiency in computer applications including database management and word processing.
Ability to adapt to change and work independently.
Knowledge of federal, state, and private payer regulations preferred.
Commitment to teamwork and professional growth.
Employment Type: Full-Time
Salary: $ 79,447.00 Per Year
We are currently seeking a motivated and experienced Remote Clinical Documentation Improvement Specialist to join our dynamic team. The successful candidate will be responsible for concurrent review of inpatient medical records to enhance the quality of physician documentation. This role involves collaborating with physicians and healthcare team members to ensure accurate and comprehensive medical records, ultimately supporting efficient coding processes.
Responsibilities:
Collaborate with physicians, case managers, coders, and other healthcare professionals to improve clinical documentation for inpatient care.
Utilize designated clinical documentation systems to identify opportunities for enhanced documentation and improved outcomes.
Provide education to internal stakeholders on compliance, coding, and clinical documentation best practices.
Evaluate documentation by medical staff and healthcare team members, ensuring alignment with organizational standards.
Analyze documentation findings and outcomes, identifying opportunities for process improvement.
Develop physician education strategies to promote accurate and complete clinical documentation.
Stay updated on CMS rules and regulations, incorporating changes into daily practice to enhance documentation processes.
Confer with physicians to review documentation clarity, completeness, and accuracy, providing coaching as needed.
Attend service line meetings, reviewing outcome information and educating physicians on improvement opportunities.
Ensure compliance with HIPAA and organizational policies and procedures.
Assist with special projects and perform other duties as assigned.
Qualifications:
Bachelor of Nursing required; BSN preferred.
Current State of Texas license or temporary/compact license to practice professional nursing.
Minimum of five years of inpatient acute care nursing experience, preferably in ICU.
Strong analytical, communication, and interpersonal skills.
Proficiency in computer applications including database management and word processing.
Ability to adapt to change and work independently.
Knowledge of federal, state, and private payer regulations preferred.
Commitment to teamwork and professional growth.
Employment Type: Full-Time
Salary: $ 79,447.00 Per Year
Source : Get It Recruit - Healthcare