RN Clinical Documentation Specialist – ICU & Acute Care

Memorial Hermann Health System; Houston (TX); On-site; USD 90,000 - 120,000; Full time

Job summary

Memorial Hermann Health System in Houston seeks a Registered Nurse for a Clinical Documentation Specialist role focused on concurrent review of inpatient records to improve physician documentation and DRG accuracy. You will collaborate with physicians and the care team to ensure complete, accurate documentation for coding and billing.

Ideal candidates hold a BSN (or MSN), Texas RN license, at least 5 years in inpatient acute care with ICU experience, and be adept at analytical thinking,

Qualifications

• Education: Bachelor of Nursing required.
• Current Texas RN license required.
• Five years inpatient, acute care bedside experience.
• ICU/critical care experience preferred.

Responsibilities

• Communicate with physicians and healthcare team to ensure comprehensive documentation reflecting treatment and diagnoses.
• Utilize the clinical documentation system to identify opportunities for improved documentation and outcomes.
• Provide education to internal customers on compliance, coding, and clinical documentation issues; assist coders as needed for accurate DRG assignment.
• Evaluate documentation daily to ensure accuracy and relevance; stay updated on CMS rules and regulations.
• Develop physician education strategies to improve documentation and reflect severity of illness.

Skills

Clinical Documentation

BSN/MSN

RN bedside experience

ICU/critical care

Education

Bachelor of Nursing

Job description

Memorial Hermann Health System in Houston seeks a Registered Nurse for a Clinical Documentation Specialist role focused on concurrent review of inpatient records to improve physician documentation and DRG accuracy. You will collaborate with physicians and the care team to ensure complete, accurate documentation for coding and billing.

Ideal candidates hold a BSN (or MSN), Texas RN license, at least 5 years in inpatient acute care with ICU experience, and be adept at analytical thinking,