Clinical Documentation & Coding Specialist

University of Texas Rio Grande Valley; Harlingen, Northern (TX, KY); Hybrid; USD 75,000 - 110,000; Full time

Job summary

The University of Texas Rio Grande Valley seeks a Clinical Documentation Specialist to promote accurate clinical documentation and coding compliance. You will review patient records, educate clinical staff, and support revenue cycle goals across multiple departments.

Ideal candidates have 5+ years in clinical coding and nursing, with CPT/ICD-10-CM/HCPCS knowledge, and experience in ambulatory or acute care settings.

Qualifications

• Five (5) years of clinical coding and/or nursing experience.
• Bachelor’s degree in Nursing or Health Information Management required.
• Experience with CPT, ICD-10-CM, HCPCS coding principles.
• Ambulatory or acute care setting experience preferred.

Responsibilities

• Obtains and promotes appropriate clinical documentation to reflect services provided.
• Performs prospective and retrospective audits of documentation for compliance with rules.
• Reviews physician and staff documentation for accuracy and billing alignment.
• Educates care teams on documentation guidelines and coding updates.
• Prepares reports and identifies trends in documentation gaps and coding deficiencies.
• Collaborates with Revenue Cycle to minimize denials and improve reimbursement.

Skills

Clinical coding

Nursing experience

Education

Bachelor’s degree in Nursing

Health Information Management

Tools

CPT/ ICD-10-CM coding knowledge

HCPCS coding standards

Job description

The University of Texas Rio Grande Valley seeks a Clinical Documentation Specialist to promote accurate clinical documentation and coding compliance. You will review patient records, educate clinical staff, and support revenue cycle goals across multiple departments.

Ideal candidates have 5+ years in clinical coding and nursing, with CPT/ICD-10-CM/HCPCS knowledge, and experience in ambulatory or acute care settings.