UTMB Faculty Group Practice · 1 month ago
Clinical Documentation Specialist (Remote -Texas Resident) - Clinical Data
United States
Full-time
Remote
Mid Level
$72K/yr - $115K/yr
3+ years expUTMB Health is a leading healthcare provider, and they are seeking a Clinical Documentation Specialist to improve the quality and accuracy of medical record documentation. The role involves collaborating with healthcare teams to ensure comprehensive documentation and accurate representation of patient status for coding and billing purposes.
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
Preferred
For nurse candidates, one year of CDI experience is highly desirable
Bachelor of Science in Nursing (BSN)
CCDS or CDIP Certification
Company
UTMB Faculty Group Practice
The University of Texas Medical Branch (UTMB) Faculty Group Practice (FGP) is comprised of over 950 faculty physicians and advanced practice providers who drive UTMB’s mission of improving health by delivering innovative education and training, pursuing cutting-edge research, and providing the highest quality patient care.
501-1000 employees
Funding
Current Stage
Late StageCompany data provided by crunchbase