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UTMB Health Clinical Documentation Specialist (Remote Work) - Clinical Data Management in Galveston, Texas

Clinical Documentation Specialist (Remote Work) - Clinical Data Management

Galveston, Texas, United States

Medical Administrative

UTMB Health

Requisition # 2302012

Minimum Qualifications:

  • Certified Registered Health Information Administrator (RHIA), or Technician (RHIT), or an associate degree in a health care related discipline with Certified Coding Specialist (CCS) certification, and a minimum of 3 years medical coding experience.


  • Registered nurse (or medical school graduate) with a minimum of 3 years inpatient clinical experience, advanced clinical expertise and an extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting.

Licenses, Registrations, or Certifications Required:

RN current license or RHIA/RHIT/CCS (medical school graduates are exempt from this MQ)


Must acquire CCDS or CDIP certification within 3 years of hire

Job Summary:

Scope: Responsible for the overall improvement of the quality and accuracy of medical record documentation through interaction with physicians, members of the patient care team and hospital coding staff.

Function: Ensures clinical documentation accurately reflects the appropriate level of service provided, severity of illness, and risk of mortality of each patient. Successfully facilitates the accurate representation of patient status that translates into coded data.

Job Duties:

  • Concurrently review inpatient admissions to identify opportunities to clarify missing or incomplete documentation.

  • Collaborate with providers, case managers, coders, and other healthcare team members to facilitate comprehensive health record documentation that reflects clinical treatment, decisions, diagnoses, and interventions.

  • Understand the general flow of health information from medical record documentation and discharge, through coding, to billing and finally to data reporting.

  • Utilize the hospital’s designated clinical documentation system to conduct reviews of the health record and identify opportunities for clarification.

  • Apply knowledge of inpatient ICD-10 coding guidelines and clinical documentation requirements to assign working MS-DRG.

  • Enter review information and working MS-DRG/APR-DRG’s with associated length of stay in the shared information system, and updates this information as needed to reflect any changes in patient’s status, procedures and treatments.

  • Communicate with providers either through discussion or in writing (e.g., formal queries) regarding missing, unclear, or conflicting health record documentation for clarification.

  • Conduct follow-up of posted queries to ensure queries have been answered and physician responses have been appropriately documented.

  • Educate and communicate clinical documentation opportunities in the appropriate hospital venues for staff and physician learning opportunity.

  • Act as a consultant to coding professionals when additional information or documentation is needed to assign coded data.

  • Collaborate with HIM/coding professionals to review individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors.

  • Assume responsibility for professional development by participating in workshops, conferences and/ or in-services.

  • Keep current with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates.

  • Contribute to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization.

  • Maintain positive and open communication with physicians, members of the patient care team, case management and hospital coding staff.

  • Adhere to internal controls and reporting structure.

  • Comply with all relevant policies, procedures, guidelines and other regulatory, compliance and accreditation standards.

  • Performs related duties as required


Demonstrate excellent observation skills, analytical thinking and problem solving plus good verbal and written communication.

Preferred Qualifications:

  • Bachelor of Science in Nursing (BSN)

  • CCDS or CDIP Certification

  • One year CDI experience

Salary Range:

Actual salary commensurate with experience.

Work Schedule:

Remote work, Monday through Friday, 8am to 5pm and as needed on occasion.

Equal Employment Opportunity

UTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a VEVRAA Federal Contractor, UTMB Health takes affirmative action to hire and advance women, minorities, protected veterans and individuals with disabilities.