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RN, Registered Nurse – Clinical Documentation


This is a Full-time position in Tyler, TX posted September 14, 2021.

DescriptionSummary:The clinical documentation specialist collaborates extensively with physicians, nursing staff, other patient caregivers and coding staff to improve the quality and completeness of documentation of care provided and coded for coordination, abstraction and submission of accurate data required by CMS.

Facilitates concurrent modifications to clinical documentation to insure commensurate reimbursement of clinical severity and services rendered to patients with a DRG based payer (Medicare, Medicaid).

Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes.

Communicates with and educates all clinical staff concerning accurate and effective clinical documentation.

Requirements:RN; BSN preferred.

Basic computer skills in word processing and spreadsheet utilization.

Excellent written and verbal communication skills.

Proficient in computer use (desktop and/or laptop).

Demonstrates basic knowledge regarding HIM coding standards.

Analytic skills necessary to accurately assess patient medical records.

Excellent interpersonal skills and ability to work on a team in order to influence physician documentation processes.

Minimum of 5 years’ recent experience in an acute care setting in a clinical nursing field required.

Prior experience in clinical documentation improvement, utilization review/management, discharge planning, quality management, or case management preferred Work Type: Full Time

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