Clinical Documentation Specialist (Remote)

Memorial Hermann; Houston (TX); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare organization is seeking an experienced CDI Specialist to enhance physician documentation quality. This remote role requires a Bachelor of Nursing degree and significant nursing experience. The position includes responsibilities such as educating healthcare teams, evaluating documentation, and ensuring compliance with regulations.

Qualifications

• RN candidate with Clinical Documentation experience, preferably with BSN or MSN.
• Five years of inpatient, acute care nursing experience; ICU experience preferred.
• Current State of Texas license or a temporary/compact license.

Responsibilities

• Communicate with healthcare team members to ensure comprehensive documentation.
• Evaluate documentation and analyze findings.
• Provide education on compliance, coding, and documentation issues.

Skills

Observation

Analytical

Problem-solving

Communication

Interpersonal skills

Education

Bachelor of Nursing degree

Job description

At Memorial Hermann, we pursue a common goal of delivering high quality, efficient care while creating exceptional experiences for every member of our community. When we say every member of our community, that includes our employees. We know that when our employees feel cared for, heard and valued, they are inspired to create moments that exceed expectations, while prioritizing safety, compassion, personalization and efficiency. If you want to advance your career and contribute to our vision of creating healthier communities, now and for generations to come, we want you to be a part of our team.

Job Summary

This position is responsible for concurrent review of inpatient medical records to identify opportunities for improving physician documentation quality. It facilitates modifications to clinical documentation through interaction with physicians (face-to-face and electronically) and other healthcare team members. The goal is to achieve a complete medical record that supports accurate and timely coding.

Job Description

Memorial Hermann is hiring an experienced, remote CDI Specialist in the following states:

• Texas
• Louisiana
• Oklahoma
• Florida
• Georgia
• Tennessee
• South Carolina

Must reside in one of the above states to be considered

Locations include Cypress, Katy, and Memorial City, with responsibilities as a float covering these areas.

Desired Skill Sets:

• RN candidate with Clinical Documentation experience, preferably with BSN or MSN
• At least 5 years of recent RN bedside experience in an acute hospital setting

Minimum Qualifications

• Bachelor of Nursing degree required
• Current State of Texas license or a temporary/compact license

• Five years of inpatient, acute care nursing experience; ICU experience preferred

• Excellent observation, analytical, problem-solving, and communication skills
• Knowledge of adult medicine and ability to assess, evaluate, and teach
• Proficiency in organization, planning, and computer skills including database, spreadsheet, and word processing

• Adaptability, flexibility, self-motivation, and independence
• Knowledge of payer regulations is a plus

• Strong interpersonal skills and positive attitude

Principal Accountabilities:

• Communicate with healthcare team members to ensure comprehensive documentation
• Use hospital’s documentation system to identify opportunities for improvement
• Provide education on compliance, coding, and documentation issues
• Evaluate documentation and analyze findings
• Develop physician education strategies and improve documentation practices
• Research and stay updated on CMS rules and regulations
• Report performance measures and review outcome data with physicians
• Coach physicians on documentation accuracy
• Participate in hospital meetings and special projects
• Adhere to HIPAA and organizational policies
• Support professional growth and serve as a mentor
• Ensure safe patient care, adhere to policies, and promote compassionate experiences
• Perform other duties as assigned