Clinical Documentation & Integrity Specialist (Remote)

Memorial Hermann Health System • Salt Lake City, UT

4d • Remote

About The Position

This position conducts concurrent reviews of inpatient medical records to identify opportunities to improve physician documentation. It facilitates documentation modifications through concurrent interactions with physicians, face-to-face and electronically, and with other healthcare team members. The objective is to ensure complete medical records that support complete, accurate, and timely coding.

The specialist reviews documentation using the hospital’s designated clinical documentation system, analyzes findings and outcomes, and works with physicians and healthcare teams to improve documentation clarity, completeness, and accuracy. The role also supports education, performance measurement, process improvement, compliance, and professional development. MDs and doctors are not eligible for consideration.

Requirements

• Bachelor of Nursing degree required; the posting also states candidates must be an RN with a BSN or MSN.
• Current Texas state license or temporary/compact license to practice professional nursing.
• At least five years of inpatient acute-care bedside nursing experience on a nursing unit; the posting specifies recent RN bedside experience in an acute hospital setting.
• Critical care/ICU nursing experience is required for consideration in the desired skill sets; the minimum qualifications list ICU experience as preferred.
• Excellent observation, analytical thinking, problem-solving, verbal communication, and written communication skills.
• Working knowledge of many areas of adult medicine.
• Ability to assess, evaluate, and teach.
• Proficiency in organization and planning.
• Computer proficiency, including databases and spreadsheet analysis, presentation programs, word processing, and Internet searching.
• Ability and willingness to seek out and accept change.
• Adaptability, flexibility, self-motivation, and ability to work independently.
• Professional team player with effective communication skills.
• Strong interpersonal skills and a positive attitude.
• Ability to maintain regular, significant contact with personnel inside and outside Memorial Hermann, in person, by telephone, or through correspondence.
• MDs and doctors cannot be considered for this position.

Nice To Haves

• Clinical Documentation experience, with preference for an RN candidate.
• Knowledge of federal, state, and private payer regulations.

Responsibilities

• Communicate with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive inpatient medical record documentation reflecting clinical treatment, decisions, and diagnoses.
• Use the hospital’s designated clinical documentation system to identify opportunities related to physician documentation and hospital outcomes.
• Provide or coordinate education for internal customers on compliance, coding, and clinical documentation, and consult with coders when additional information or documentation is needed to assign the correct DRG.
• Evaluate medical staff and healthcare team documentation day to day in accordance with the hospital’s designated clinical documentation system.
• Gather and analyze information related to documentation findings and outcomes.
• Contribute to a positive working environment and perform other duties as assigned or directed.
• Develop physician education strategies that promote complete and accurate documentation and correct negative trends.
• Identify patterns, trends, variances, and opportunities to improve documentation review and processes.
• Research literature and keep current with CMS rules and regulations, incorporating changes into daily practice.
• Assist in developing and reporting performance measures to medical staff and other departments, and prepare physician-specific data.
• Meet with key physicians to review outcome information, including physician profile data when relevant, as it relates to documentation and correct DRG designation.
• Coach physicians to improve documentation so it accurately reflects intensity of services and severity of illness; document conferences and results.
• Attend hospital service-line meetings, review outcome information, and educate physicians about service-line-specific improvement opportunities.
• Comply with HIPAA and Code of Conduct policies.
• Assist with special projects as needed.
• Demonstrate competency in customer service, job skills, resource management, teamwork, and innovation.
• Ensure safe care for patients, staff, and visitors, and adhere to organizational policies, procedures, and standards, including budget, time, supply, productivity, and service-quality expectations.
• Pursue professional growth and development through mandatory and continuing education and skills competency; support department goals and serve as a preceptor, mentor, and resource to less experienced staff.
• Model service standards by providing safe, caring, personalized, and efficient experiences to patients and colleagues.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level