Clinical Documentation Specialist

Location: Remote

Facility: Seton Family of Hospitals

Department: Clinic Integrity Documentation

Schedule: Full-time | Monday - Friday | 8:00 am - 4:00 pm CST

Salary: $79,511.52 - $110,834.59 per year

• Optimize Clinical Documentation: Drive measurable improvements in medical record completeness, accuracy, and overall data quality.
• Manage DRG & Database Inputs: Conduct timely admission reviews to assign and log accurate working Diagnosis Related Groups (DRGs).
• Cultivate Provider Collaboration: Partner extensively with physicians and mid-level providers to resolve documentation queries prior to patient discharge.
• Capture Care Severity: Ensure medical records precisely reflect the true severity of illness and the full level of healthcare services delivered.

Licensure / Certification / Registration:

• One or more of the following required :
  • Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
  • Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.
  • Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
  • Clinical Documentation Prof. credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
  • Registered Nurse credentialed from the Texas Board of Nursing obtained prior to hire date or job transfer date.
  • Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
  • Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.

Education:

• High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.

• 1+ years of experience in a Clinical Documentation Integrity position needed
• Second Level Review experience and Certified Clinical Documentation Specialist (CCDS) strongly preferred
• Active Registered Nursing license in state of residence needed