Clinical Documentation Coordinator - FT - Texoma - ROC

Universal Health Services; Edinburg (TX); On-site; USD 70,000 - 95,000; Full time

Job summary

Universal Health Services seeks a Clinical Documentation Improvement Specialist to enhance the accuracy and completeness of clinical documentation across facilities. You will promote collaboration between clinical reviewers, coders, and physicians to optimize reimbursement and patient outcome reporting.

The role requires strong communication, critical thinking, and knowledge of Medicare reimbursement. Travel between facilities is expected as needed, with a focus on education and process

Qualifications

• Excellent written and verbal communication needed.
• 3–5 years clinical experience in acute care or direct patient care setting.
• Willingness to travel between facilities as needed.
• Medicare reimbursement knowledge and coding structures preferred, not required.
• Computer literacy is essential.

Responsibilities

• Improve completeness and quality of clinical documentation.
• Foster partnership among clinical reviewers, coders, and physicians to improve documentation and reimbursement.
• Clarify and specify clinical documentation to support accurate severity of illness, intensity of care, and risk of mortality.
• Educate health care team on ongoing basis about documentation and coding processes.

Skills

Excellent communication

Critical thinking

Attention to detail

Clinical knowledge

Independent work

Medicare knowledge (preferred)

Computer literacy

Compliance awareness

Education

Nursing degree

Healthcare-related degree

Advanced degree acceptable

Job description

Responsibilities

POSITION SUMMARY: Responsible for improving the overall quality and completeness of clinical documentation. Promotes a partnership between the concurrent clinical reviewers, medical record coders, and physicians to improve documentation and reimbursement for STHS. Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians, advocating for appropriate reimbursement. Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patient's true severity of illness, intensity of care, and risk of mortality. Educates all members of the health care team on an ongoing basis.

Qualifications

• 1. Excellent written and verbal communication skills required.
• 2. Excellent critical thinking skills required and must be detail oriented.
• 3. Knowledge of age-specific needs and elements of disease process and related procedures required. Strong broad based clinical knowledge and understanding of pathology/physiology of disease processes.
• 4. Ability to work independently in a time-oriented environment is essential.
• 5. Working knowledge of Medicare reimbursement system and coding structures preferred, by not required.
• 6. Computer literacy essential.
• 7. 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.

EDUCATION / LICENSURE

• 1. Associate, Bachelor or Master's Degree in Nursing or Healthcare Related Field; Advanced degree such as International MD degree acceptable.
• 2. Minimum of 3-5 years clinical experience in an acute care or direct patient care setting; Critical Care, Medical/Surgical or Emergency Department nursing preferred.
• 3. Must be able to travel between facilities as needed.

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.