Responsible for improving the quality and accuracy of medical record documentation through collaboration with physicians, patient care team members, and hospital coding staff.
Ensures clinical documentation accurately reflects the appropriate level of service, severity of illness, and risk of mortality for each patient, supporting accurate coded data.
Review inpatient admissions concurrently, identify missing or incomplete documentation, and communicate clarification needs to providers through discussion or formal queries.
Collaborate with providers, case managers, coders, and other healthcare team members to support complete health record documentation, educate staff on documentation opportunities, and assist with problematic cases.
Maintain current knowledge of coding guidelines, compliance, reimbursement, and regulatory updates while adhering to internal controls, policies, and accreditation standards.
Certified Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or an associate degree in a healthcare-related discipline with Certified Coding Specialist (CCS) certification, plus at least 3 years of medical coding experience.
Alternatively, a registered nurse or medical school graduate with at least 3 years of inpatient clinical experience, advanced clinical expertise, and broad knowledge of complex disease processes in an inpatient setting.
Required license or certification:
- Current RN license or RHIA/RHIT/CCS
- Must obtain CCDS or CDIP certification within 3 years of hire
Preferred qualifications:
- 1 year of CDI experience for nurse candidates
- Bachelor of Science in Nursing (BSN)
- CCDS or CDIP certification
Knowledge and skills:
- Excellent observation skills
- Analytical thinking and problem-solving ability
- Strong verbal and written communication skills
Location
Texas, US
Employment Type
Full-time
Experience Level
Intermediate Level
Salary Range
$71,923 - $115,077
Remote work allowed
Yes
Posted
4 weeks ago