Clinical Documentation Specialist - Reimbursement & Quality

Universal Health Services, Inc.; Edinburg (TX); On-site; USD 80,000 - 110,000; Full time

Job summary

Universal Health Services, Inc. is seeking a Clinical Documentation Improvement professional to drive the accuracy and completeness of clinical documentation across facilities.

The role focuses on partnering with reviewers, coders, and physicians to optimize documentation and appropriate reimbursement. The position involves educating the care team and ensuring the documentation reflects true severity of illness and risk of mortality, with travel between facilities as needed.

Qualifications

• Excellent written and verbal communication skills.
• Strong critical thinking and high attention to detail.
• Broad clinical knowledge of pathology/physiology; age-specific care.
• Ability to work independently in a fast-paced environment.
• Familiarity with Medicare reimbursement and coding structures preferred.
• Computer literacy and proficient use of health information systems.
• Commitment to compliance and Code of Conduct; report issues promptly.

Responsibilities

• Improve the overall quality and completeness of clinical documentation.
• Promote partnership between reviewers, coders, and physicians to improve documentation and reimbursement.
• Clarify and specify clinical documentation through interaction with physicians; advocate for appropriate reimbursement.
• Support accuracy of clinical information used for measuring hospital outcomes; reflect severity of illness and intensity of care.
• Educate health care team on an ongoing basis.

Skills

Written communication

Critical thinking

Clinical knowledge

Independence

Medicare knowledge

Computer literacy

Compliance

Education

Associate/Bachelor/Master in Nursing or Healthcare

Advanced degree acceptable

Willingness to travel between facilities

Job description

Universal Health Services, Inc. is seeking a Clinical Documentation Improvement professional to drive the accuracy and completeness of clinical documentation across facilities.

The role focuses on partnering with reviewers, coders, and physicians to optimize documentation and appropriate reimbursement. The position involves educating the care team and ensuring the documentation reflects true severity of illness and risk of mortality, with travel between facilities as needed.