Remote CDI Specialist — Elevate Clinical Documentation

Memorial Hermann Health System; Houston (TX); On-site; USD 75,000 - 110,000; Full time

Job summary

Memorial Hermann Health System seeks an experienced RN to perform concurrent review of inpatient medical records, identifying opportunities to improve physician documentation quality and DRG accuracy. The role requires collaboration with physicians and care teams to ensure complete and accurate documentation for timely coding.

The ideal candidate has 5+ years of bedside RN experience in an acute hospital, BSN or MSN, and familiarity with clinical documentation systems.

Qualifications

• RN with BSN or MSN is required.
• At least 5 years of recent inpatient RN bedside experience in an acute hospital setting.
• Critical care/ICU nursing experience preferred.
• Experience with clinical documentation and documentation improvement.

Responsibilities

• Coordinate concurrent review of inpatient records to improve physician documentation quality.
• Interact with physicians and health care team to obtain necessary information for complete documentation.
• Educate internal customers on compliance, coding and documentation issues.
• Contribute to performance measures and physician-specific data reporting.
• Assist in developing physician education strategies to improve documentation quality.

Skills

Observation skills

Analytical thinking

Communication (verbal & written)

Organization & planning

Computer literacy (databases, Excel, P

Education

BSN

MSN

Tools

Clinical Documentation System

Job description

Memorial Hermann Health System seeks an experienced RN to perform concurrent review of inpatient medical records, identifying opportunities to improve physician documentation quality and DRG accuracy. The role requires collaboration with physicians and care teams to ensure complete and accurate documentation for timely coding.

The ideal candidate has 5+ years of bedside RN experience in an acute hospital, BSN or MSN, and familiarity with clinical documentation systems.