The University of Texas Medical Branch · 3 weeks ago
Clinical Documentation Specialist (Remote -Texas Resident) - Clinical Data
United States
Full-time
Remote
Mid Level
$72K/yr - $115K/yr
3+ years expThe University of Texas Medical Branch is dedicated to improving healthcare quality, and they are seeking a Clinical Documentation Specialist. This role is responsible for enhancing the accuracy of medical record documentation through collaboration with healthcare professionals and ensuring compliance with coding guidelines.
Hospital & Health Care
Responsibilities
Concurrently review inpatient admissions to identify opportunities to clarify missing or incomplete documentation
Collaborate with providers, case managers, coders, and other healthcare team members to facilitate comprehensive health record documentation that reflects clinical treatment, decisions, diagnoses, and interventions
Understand the general flow of health information from medical record documentation and discharge, through coding, to billing, and finally to data reporting
Utilize the hospital’s designated clinical documentation system to conduct reviews of the health record and identify opportunities for clarification
Apply knowledge of inpatient ICD-10 coding guidelines and clinical documentation requirements to assign working MS-DRG
Enter review information and working MS-DRG/APR-DRG’s with associated length of stay in the shared information system, and update this information as needed to reflect any changes in the patient’s status, procedures, and treatments
Communicate with providers either through discussion or in writing (e.g., formal queries) regarding missing, unclear, or conflicting health record documentation for clarification
Conduct follow-up of posted queries to ensure queries have been answered and physician responses have been appropriately documented
Educate and communicate clinical documentation opportunities in the appropriate hospital venues for staff and physician learning opportunities
Act as a consultant to coding professionals when additional information or documentation is needed to assign coded data
Collaborate with HIM/coding professionals to review individual problematic cases and ensure the accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors
Assume responsibility for professional development by participating in workshops, conferences and/ or in-services
Keep current with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates
Contribute to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization
Maintain positive and open communication with physicians, members of the patient care team, case management, and hospital coding staff
Adhere to internal controls and reporting structure
Comply with all relevant policies, procedures, guidelines, and other regulatory, compliance, and accreditation standards
Performs related duties as required
Qualification
Required
Certified Registered Health Information Administrator (RHIA), Technician (RHIT), or an associate degree in a healthcare-related discipline with Certified Coding Specialist (CCS) certification, and a minimum of 3 years of medical coding experience
Registered nurse (or medical school graduate) with a minimum of 3 years inpatient clinical experience, advanced clinical expertise and an extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting
RN current license or RHIA/RHIT/CCS (medical school graduates are exempt from this MQ)
Must acquire CCDS or CDIP certification within 3 years of hire
Demonstrate excellent observation skills, analytical thinking, and problem-solving, plus good verbal and written communication
Preferred
For nurse candidates, one year of CDI experience is highly desirable
Bachelor of Science in Nursing (BSN)
CCDS or CDIP Certification
Company
The University of Texas Medical Branch
The University of Texas Medical Branch is a component of the University of Texas System located in Galveston, Texas
10001+ employees
H1B Sponsorship
The University of Texas Medical Branch has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (73)
2024 (66)
2023 (52)
2022 (57)
2021 (49)
2020 (50)
Funding
Current Stage
Late StageTotal Funding
$35MKey Investors
National Institute of Allergy and Infectious Diseases
2024-09-13Grant
2019-04-09Grant· $35M
Leadership Team
Donna Sollenberger
EVP and CEO, Health System
Recent News
2025-10-30
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EIN Presswire
2025-08-25
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