Clinical Documentation Specialist

Nacogdoches Medical Center; Nacogdoches (TX); On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401(k) match

Paid time off

Career development

Health savings account

Employee discounts

Voluntary benefits

Job summary

Nacogdoches Medical Center seeks a Clinical Documentation Specialist (RN) to perform concurrent and retrospective reviews of inpatient Medicare records, ensuring accurate documentation of patient complexity and appropriate coding for reimbursement.

The role supports quality reporting and improves physician documentation to reflect severity of illness and risk of mortality, contributing to compliant reimbursement and optimal care outcomes.

Qualifications

• Current, valid RN license and relevant education.
• Three years of clinical experience in an acute care setting.
• RN licensure and Licensed Masters Social Worker are required.
• FLSA status: Exempt.

Responsibilities

• Perform concurrent and retrospective reviews of inpatient Medicare records.
• Facilitate physician documentation to reflect severity of illness and risk of mortality.
• Support reporting of care quality outcomes and accurate reimbursement.

Skills

Concurrent & retrospective reviews

Documentation improvement

Quality reporting & reimbursement

Certifications due by 3 months

Education

RN license

Job description

Overview

Embark on a rewarding career with Nacogdoches Medical Center hospital. If you are a compassionate healthcare professional eager to contribute to patient care, this is your opportunity where your skills make a difference every day. Join us in delivering exceptional healthcare with a personal touch.

At Nacogdoches Medical Center, We Understand That Our Greatest Asset Is Our Dedicated Team Of Professionals. That’s Why We Offer More Than a Job – We Provide a Comprehensive Benefit Package That Prioritizes Your Health, Professional Development, And Work-life Balance.

The Available Plans And Programs Include:

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

Note: Eligibility for benefits may vary by location and is determined by employment status

Job Summary

The Clinical Documentation Specialist provides clinically based concurrent and retrospective review of inpatient Medicare medical records to evaluate the utilization and documentation of acute care services, which includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Plays a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.

Qualifications

• Minimum Education: Must possess a current, valid RN license and relevant education.
• Minimum Experience: Three years clinical experience acute setting.
• Required Licensure: Registered nurse, Licensed Masters Social Worker
• FLSA Status: Exempt

Skills

• Note – Required certifications are to be completed by 3 months of employment.

Organization Description

Nacogdoches Medical Center has been serving the East Texas community for nearly 50 yearswith a focus on caring for patients and a strong team environment. Service lines at the hospital include obstetrics and gynecology, cardiology (including a cath lab and electrophysiology capabilities), cancer care, neuroscience (Brainlab technology and stroke treatments) and weight loss surgery. Theseservices help the medical center provide treatment options close to home for patients. Join our team!

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.

Tenet participates in the E-Verify program. Follow the link below for additional information.

E-Verify: http://www.uscis.gov/e-verify

The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations.

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.

Minimum Education: Must possess a current, valid RN license and relevant education.

Minimum Experience: Three years clinical experience acute setting.

Required Licensure: Registered nurse, Licensed Masters Social Worker

FLSA Status: Exempt

Skills

• Note – Required certifications are to be completed by 3 months of employment.