Join our dynamic team at UTMB Health as we seek a dedicated Clinical Documentation Specialist to enhance the quality and accuracy of medical record documentation. This remote position is open exclusively to residents of Texas, allowing you to support our mission from the comfort of your home.

Minimum Qualifications:
To be considered for this role, you must hold one of the following credentials:

• Certified Registered Health Information Administrator (RHIA) or Technician (RHIT); or
• An associate degree in a healthcare-associated field paired with a Certified Coding Specialist (CCS) certification, alongside a minimum of 3 years of medical coding experience.

Alternatively, if you are a registered nurse or medical school graduate with at least 3 years of inpatient clinical experience and a robust understanding of complex disease processes, we welcome your application.

Essential Licenses, Registrations, or Certifications:

• RN license or RHIA/RHIT/CCS (medical school graduates may be exempt).
• You will need to obtain either CCDS or CDIP certification within your first 3 years of employment.

Preferred Qualifications:

• For nursing candidates, one year of experience in Clinical Documentation Improvement (CDI) is highly beneficial.
• A Bachelor of Science in Nursing (BSN) is preferred.
• CCDS or CDIP certification is an advantage.

Role Overview:
As a vital member of our healthcare team, you will play a crucial role in improving documentation quality by collaborating with physicians, patient care teams, and coding specialists. Your expertise will ensure that clinical documentation accurately reflects the level of service, severity of illness, and mortality risk for each patient, which is essential for coding and reimbursement accuracy.

Key Responsibilities:

• Conduct concurrent reviews of inpatient admissions to identify opportunities for clarifying documentation gaps.
• Engage with providers, case managers, coders, and the healthcare team to foster comprehensive health record documentation reflective of treatment, decisions, diagnoses, and interventions.
• Navigate the flow of health information from medical record documentation to billing and data reporting.
• Utilize the designated clinical documentation system for health record reviews and documentation clarifications.
• Apply knowledge of inpatient ICD-10 coding guidelines and clinical documentation requirements for accurate MS-DRG assignment.
• Maintain and update review information, including working MS-DRGs and associated lengths of stay, in the shared information system as patient statuses, procedures, and treatments evolve.
• Communicate with providers about unclear or conflicting documentation and follow up on posted queries for resolution.
• Educate staff and physicians about documentation opportunities to enhance overall quality.
• Serve as a consultant to coding professionals regarding additional required documentation.
• Collaborate with HIM/coding professionals on challenging cases to assure precise coding accuracy.
• Take charge of your professional growth through workshops, conferences, and continuing education.
• Stay informed of changes in coding guidelines, compliance, and related regulatory updates.
• Uphold a positive work environment and perform additional duties as assigned to support the organization’s efforts.
• Maintain effective communication with physicians and the patient care team, adhering to internal controls and compliance standards.

Skills and Abilities:
We value individuals who demonstrate excellent observational skills, analytical prowess, and problem-solving abilities. Strong verbal and written communication skills are essential.

Compensation:
Salary will be determined according to experience and qualifications.

Work Schedule:
Enjoy the flexibility of remote work from Monday to Friday, 8 am to 5 pm, with occasional additional hours as required.

Equal Opportunity Employment:
UTMB Health is committed to fostering an inclusive workforce and prohibits discrimination based on race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by law. As a Federal Contractor, we actively pursue hiring and promoting protected veterans and individuals with disabilities.

If you are ready to make a difference in healthcare documentation, we encourage you to apply and be part of our mission!