Clinical Documentation Specialist - Professional Ambulatory

Texas Children's Hospital; Houston (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

Texas Children’s Hospital seeks a Professional Ambulatory Clinical Documentation Specialist to improve CPT/ICD coding accuracy through physician education and documentation training. You will lead reviews, provide feedback, and design programs to optimize reimbursement while ensuring compliance across ambulatory services.

The role emphasizes training, root-cause analysis, and collaboration with physicians and staff to uphold high-quality medical record documentation and coding standards.

Qualifications

• Associate degree required; bachelor's preferred.
• Four years healthcare experience may substitute for the degree.
• Certifications in coding (CPC, CCDS, CDIP, CCS-P, CIPC, COC, CDEO, CCDS-O) required or preferred.

Responsibilities

• Review physician documentation for CPT/ICD coding accuracy.
• Educate physicians and staff on documentation and coding best practices.
• Develop and implement training to improve documentation quality and reimbursement.

Skills

Healthcare experience

Education & training

Documentation & coding education

Regulatory compliance

Education

Associate degree

Bachelor's degree preferred

Job description

Job Description

We’re hunting for a Professional Ambulatory Clinical Documentation Specialist, someone who’s ready to be part of the best ranked children’s hospital in Texas, and among the best in the nation. In this position, you will be responsible for the reviewing, education, development, and training of our Physicians and staff as it relates to reimbursement and CPT and ICD coding compliance.

We’re hunting for a Professional Ambulatory Clinical Documentation Specialist, someone who’s ready to be part of the best ranked children’s hospital in Texas, and among the best in the nation. In this position, you will be responsible for the reviewing, education, development, and training of our Physicians and staff as it relates to reimbursement and CPT and ICD coding compliance.

Think you’ve got what it takes?

Job Duties & Responsibilities

• Develops and implements a method by which each TCPA & TCPSO physician has a representative sample of his/her medical records reviewed on a routine and frequent basis.
• Provides feedback to physician and Director on the educational opportunities found from the reviews. Recommends improvement opportunities to documentation practices and coding changes to physician based on information.
• Provides feedback to the Director on any Medicaid compliance issue found from the reviews.
• Develops and implements training programs for Physicians, Front Office, and CBO staff to reinforce and/or change the documentation and coding behaviors found from the review.
• Educates and reinforces the most appropriate documentation used to optimize quality and reimbursement that TCPA & TCPSO physicians utilize. Where appropriate, this should include education on coding guidelines were quality documentation is already present but not coded to the appropriate level
• Focused on root cause identification and process improvement specific to documentation accuracy and completeness.
• Engages in process and quality improvement initiatives.
• Reviews and interprets the Federal Registry and other relevant publications on a current and regular basis to be aware of coding changes that may affect TCPA & TCPSO as well as the industry.
• Responds directly to all telephone and written requests for documentation and coding information accurately and timely.
• Acts as a risk adjustment documentation and coding resource, including education and physician engagement.

Skills & Requirements

• Required associate degree with a preferred bachelor's degree
• Four years of healthcare experience will substitute for the required associate degree
• Required Licenses and Certifications (one of the following):
• CPC - Cert-Cert Professional Coder American Academy of Professional Coders (AAPC)
• CCDS DOC - Cert-Cert Clinical Doc. SPCLST Association of Clinical Documentation Improvement Specialist (ACDIS)
• CDIP - Cert-Clinical Doc. Impr. PROF American Health Information Management Association (AHIMA)
• CCS-P - Cert-CCS-P Physician Based American Health Information Management Association (AHIMA)
• CIPC - Certified Inpatient Coder American Academy of Professional Coders (AAPC)
• COC - Certified Outpatient Coder American Academy of Professional Coders (AAPC)
• CDEO Certified Documentation Expert Outpatient American Academy of Professional Coders (AAPC)
• CCDS-O Certified Clinical Documentation Specialist Outpatient Association of Clinical Documentation Improvement Specialist (ACDIS)
• Preferred Pediatric Experience

About Us

Since 1954, Texas Children’s has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children’s hospital in Texas, and among the top in the nation by U.S. News & World Report as well as recognition from Houston Business Journal as one of this city’s Best Places to Work for ten consecutive years.

Texas Children’s comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Tower for pediatric research; Texas Children ’ s Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children ’ s Hospital West Campus, a community hospital in suburban West Houston; Texas Children ’ s Hospital The Woodlands, the first hospital devoted to children ’ s care for communities north of Houston; and Texas Children’s Hospital North Austin, the new state‑art facility providing world‑class pediatric and maternal care to Austin and Central Texas families. We have also created Texas Children ’ s Health Plan, the nation ’ s first HMO focused on children; Texas Children ’ s Pediatrics, the largest pediatric primary care network in the country; Texas Children ’ s Urgent Care clinics that specialize in after‑hours care tailored specifically for children; and a global health program that is channeling care to children and women all over the world. Texas Children ’ s Hospital is affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation.

To join our community of 15,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities.

Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.