CLINICAL DOCUMENTATION SPECIALIST

University of Texas Rio Grande Valley; Edinburg (TX); On-site; USD 70,000 - 95,000; Full time

Job summary

The University of Texas Rio Grande Valley seeks a Clinical Documentation Specialist to promote accurate clinical documentation by reviewing patient records and educating the care team to ensure documentation reflects the level of service rendered.

You will conduct complex reviews and audits of physician billing, identify documentation gaps, and provide feedback to clinicians and revenue cycle staff to improve reimbursement and compliance with CPT, ICD-10-CM, and HCPCS coding guidelines.

Qualifications

• Bachelor's degree in Nursing, Health Information Management or related field from an accredited university.
• Five years of clinical coding and/or nursing experience preferred.
• Certified Professional Coder (CPC) or CCS-P/CPMA certification preferred.

Responsibilities

• Obtains and promotes appropriate clinical documentation through interaction with clinical staff and physicians to ensure documentation is complete and reflects the level of service rendered.
• Conducts complex reviews of physician/provider billing compliance activities in accordance with applicable laws, regulations, rules or policies.
• Performs prospective and retrospective audits of documentation to confirm compliance with documentation and coding rules and government regulations; provides feedback and education related to audit results.

Skills

Clinical documentation

Auditing

Education/training

Education

Bachelor's degree in Nursing or Health Information Management

Job description

CLINICAL DOCUMENTATION SPECIALIST

Posting Number: SRGV9164

Number of Vacancies: 1

Location: Harlingen, Texas

Department: School of Medicine/ Revenue Cycle

FLSA: Exempt

Scope of Job:

To promote appropriate clinical documentation through collaborationwith the School of Medicine clinical staff by reviewing patientdocuments, assessing for accuracy and educating the patient careteam to ensure guidelines are met and appropriate process isfollowed.

Description of Duties:

• Obtains and promotes appropriate clinical documentation throughinteraction with clinical staff and physicians to ensuredocumentation is complete, accurate and reflects the level ofservice rendered to patients.
• Conducts complex reviews of physician/provider billing complianceactivities in accordance with applicable laws, regulations, rulesor policies.
• Performs prospective and retrospective audits of documentation toconfirm compliance with documentation and billing rules andgovernment regulations. Provides feedback and education related toaudit results.
• Reviews documentation by physicians and clinical staff as well aslab results, diagnostic information and treatment plans to assureaccuracy.
• Reviews files to identify documentation gaps and requestsclarification from physicians and other caregivers of uncleardiagnoses, patient complications, procedures and clinicaldocumentation.
• Works closely with Revenue Cycle billing/collection staff toensure accurate physician reimbursement is achieved and claimsdenials are reduced by ensuring documentation integrity.
• Educates all members of the patient care team on documentationguidelines on an ongoing basis.
• Develops and presents on-going documentation education for staffincluding coders, physicians, residents, clinical staff, and alliedhealth professionals.
• Prepares reports, provides supporting evidence and makesrecommendations regarding identified documentation and codingdeficiencies or gaps. Identifies trends and provides feedback tomedical staff, coders, and management.
• Acts as a knowledge expert to service providers and codersthrough familiarity with coding conventions.
• Works closely with Revenue Cycle coding staff on ClinicalDocumentation Improvement (CDI) activities, processes, andprocedures.
• Provides education for medical student and residentorientation/development and other times as necessary.
• Presents recommendations for quality management and processesimprovement opportunities regarding workflow and or policies andprocedures as necessary.
• Maintains a thorough understanding of CPT, ICD-10 CM, and HCPCScoding principles, and keeps current with changes in codingguidelines, compliance, reimbursement, and other relevantregulatory updates.
• Maintains positive and open communication with physicians,management and Revenue Cycle team.
• Adheres to internal controls and reporting structure.
• Performs other duties as assigned.

Supervision Received:

General supervision from assigned supervisor.

Supervision Given:

Direct supervision of assigned staff.

Required Education:

Bachelor's degree in Nursing, Health Information Management orrelated field from an accredited University.

Preferred Education:

None.

Licenses/Certifications:

Certified Professional Coder (CPC) from American AcademyProfessional Coders (AAPC), or Certified Coding Specialist – P (CCS– P) from the American Health Information Management Association(AHIMA), or Certified Professional Medical Auditor (CPMA), or,Attime of hire, Registered Health Information Technician (RHIT) fromthe American Health Information Management Association (AHIMA), orRegistered Health Information Administrator (RHIA) from theAmerican Health Information Management Association (AHIMA), orCurrent State of Texas Professional Nursing License (RN), and mustobtain one of the coding certifications stated above (CPC, CCS-P,CPMA) within 6 months of employment.Preferred: Certified ClinicalDocumentation Improvement Practitioner (CDI) from the AmericanHealth Information Management Association (AHIMA).

Required Experience:

Five (5) years of clinical coding and/or nursing experience in anambulatory setting or in an acute care facility. May substituterequired degree with additional years of experience on a one-to-onebasis.

Preferred Experience:

Five years of clinical documentation experience in an acute carefacility.

Equipment:

Use of standard office equipment.

Working Conditions:

Needs to be able to successfully perform all required duties.Office and patient care environment; some travel and weekend workis required. UTRGV is a distributed institution, which requirespresence at multiple locations throughout the Rio GrandeValley.

Other:

Has a good understanding of all clinical information systems anddata flow across the continuum. Ability to communicate effectively,written and verbal. Tact, diplomacy, discretion, andconfidentiality of medical information required in allmatters.

Physical Capabilities:

N/A

Employment Category:

Full-Time

Minimum Salary:

Commensurate with Experience

Posted Salary:

Commensurate with Experience

Position Available Date:

10/05/2025

Grant Funded Position:

No

EEO Statement:

It is the policy of The University of Texas Rio Grande Valley topromote and ensure equal employment opportunities for allindividuals without regard to race, color, national origin, sex,age, religion, disability, sexual orientation, gender identity orexpression, genetic information or protected veteran status. Inaccordance with the requirements of Title VII of the Civil RightsAct of 1964, the Title IX of the Education Amendments of 1972,Section 504 of the Rehabilitation Act of 1973, and the Americanswith Disabilities Act of 1990, as amended, our University iscommitted to comply with all government requirements and ensuresnon-discrimination in its education programs and activities,including employment. We encourage women, minorities anddifferently abled persons to apply for employment positions ofinterest.

Additional Information:

UTRGV is a distributed location institution and working location issubject to change based on need.

All UTRGV employees are required to have a criminal backgroundcheck (CBC). Incomplete applications will not be considered.

Substitutions to the above requirements must have prior approval from the VP of Human Resources.