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Clinical Documentation & Integrity Specialist
Memorial Hermann Health System. Conduct concurrent reviews of inpatient medical records to identify opportunities to improve physician documentation .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation improvement, coding accuracy, and physician education strategies while ensuring compliance with healthcare regulations. Proficient in analyzing documentation patterns and collaborating with healthcare teams to enhance patient care outcomes.
Highest-signal resume keywords
RN With BSN Or MSNInpatient Acute Care ExperienceCritical Care ICU Nursing ExperienceClinical Documentation ImprovementKnowledge Of Federal And State Regulations
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Documentation AnalysisCoding AccuracyDRG AssignmentPerformance Measure ReportingDatabase AnalysisSpreadsheet AnalysisPresentation SkillsWord ProcessingInternet Searching
Soft Skills
Analytical ThinkingProblem SolvingVerbal CommunicationWritten CommunicationInterpersonal Skills
Tools & Technologies
Clinical Documentation System
Certifications & Qualifications
Current State Of Texas Nursing LicenseBachelor Of Nursing
Industry Keywords
HIPAA ComplianceCMS Rules And RegulationsPatient CareHealthcare Team CollaborationDocumentation Patterns
About the role
Key responsibilities & impact- Conduct concurrent reviews of inpatient medical records to identify opportunities to improve physician documentation
- Facilitate clinical documentation modifications through interaction with physicians and healthcare team members
- Support complete, accurate, and timely coding and correct DRG assignment
- Communicate with physicians, case managers, coders, and other healthcare team members regarding medical record documentation
- Use the designated clinical documentation system to identify documentation and hospital outcome opportunities
- Provide or coordinate education on compliance, coding, and clinical documentation issues
- Evaluate documentation by medical staff and healthcare teams
- Gather and analyze documentation findings and outcomes
- Develop physician education strategies to improve documentation completeness and accuracy
- Identify documentation patterns, trends, variances, and process improvement opportunities
- Research literature and monitor CMS rules and regulations
- Assist with developing and reporting performance measures and physician-specific data
- Confer with and coach physicians regarding documentation clarity, completeness, intensity of services, severity of illness, and DRG designation
- Attend hospital service line meetings and educate physicians on improvement opportunities
- Comply with HIPAA and Code of Conduct policies
- Assist with special projects and other assigned duties
- Promote safe, compassionate, personalized, and efficient experiences for patients and colleagues
Requirements
What you’ll need- RN with a BSN or MSN
- Bachelor of Nursing required
- Current State of Texas license or temporary/compact license to practice professional nursing
- At least 5 years of recent RN bedside experience in an acute hospital setting
- Five years of inpatient, acute care bedside experience on a nursing unit
- Critical care, ICU nursing experience required for consideration
- Excellent observation, analytical thinking, problem solving, verbal and written communication skills
- Working knowledge of many areas of adult medicine
- Ability to assess, evaluate, and teach
- Proficiency in organization and planning
- Proficiency in computer usage, including database 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
- Knowledge of federal, state, and private payer regulations preferred
- Professional, team-oriented, and strong interpersonal skills
- Must not be an MD or doctor
Benefits
Comp & perks- Mandatory/continuing education and skills competency
- Professional growth and development opportunities
- Preceptor, mentor and resource support for less experienced staff