Clinical Documentation Champion: Elevate Care Quality

Texoma-Medical-Center; Edinburg (TX); On-site; USD 70,000 - 110,000; Full time

Job summary

Universal Hospital Services Inc. seeks a highly capable Clinical Documentation Specialist to enhance documentation quality and accuracy across acute care settings.

You will collaborate with physicians, reviewers, and coders to ensure precise coding and justified reimbursement, while educating teams on compliant documentation practices. The role emphasizes improving patient outcome data, severity of illness measures, and transparency in documentation.

Qualifications

• Excellent written and verbal communication skills required.
• Excellent critical thinking skills required and must be detail oriented.
• Knowledge of age-specific needs and elements of disease process and related procedures required.
• Ability to work independently in a time-oriented environment is essential.
• Working knowledge of Medicare reimbursement system and coding structures preferred, by not required.
• Computer literacy essential.
• Must demonstrate commitment and adherence to STHS’s Compliance Program and Code of Conduct through compliance with all policies and procedures, the Code of Conduct, attendance at required training and immediately reporting suspected compliance issue(s) to the Compliance Officer.

Responsibilities

• Improve the overall quality and completeness of clinical documentation.
• Promote a partnership between concurrent clinical reviewers, medical record coders, and physicians to improve documentation and reimbursement.
• Facilitate clarification and specificity to clinical documentation through interaction with physicians and advocate for appropriate reimbursement.
• Support the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
• Educate all members of the health care team on an ongoing basis.

Skills

Communication

Critical thinking

Attention to detail

Age-specific care

Medicare knowledge

Computer literacy

Compliance awareness

Education

Associate/Bachelor/Master in Nursing or Healthcare

3-5 years clinical experience

Travel between facilities

Job description

Universal Hospital Services Inc. seeks a highly capable Clinical Documentation Specialist to enhance documentation quality and accuracy across acute care settings.

You will collaborate with physicians, reviewers, and coders to ensure precise coding and justified reimbursement, while educating teams on compliant documentation practices. The role emphasizes improving patient outcome data, severity of illness measures, and transparency in documentation.