Clinical Documentation Specialist

Office Location
The University of Texas Rio Grande Valley
1201 W. University Drive
Human Resources
MASS Building 2 nd Floor
Edinburg, TX 78539

Edinburg:
Brownsville:
Office hours:
Monday-Friday
8:00a.m.

- 5:00p.m.

Faculty Recruitment:
College of Engineering & Computer Science: cecs

Robert

C. Vackar College of Business & Entrepreneurship: cobe

Dear Applicant, Human Resources will not be held responsible for redacting any confidential information from the documents you attach with your application. The confidential information includes the following:
* Date of Birth
* Gender
* Ethnicity/Race Please make sure that you omit this information prior to submission. We are advising that Human Resources will be forwarding your application to the department as per your submission. The University of Texas Rio Grande Valley reserves the right to discontinue accepting applications prior to the stated close date of this position, after meeting the posting requirement of three (3) calendar days.

If you have any questions, please visit our Careers site at https://careers.utrgv.edu for detailed contact information.

Position Information

Posting Number

Posting Number SRGV
9164

Working Title

Working Title CLINICAL DOCUMENTATION SPECIALIST

Number of Vacancies

Number of Vacancies 1

Location

Department

Department School of Medicine/ Revenue Cycle

FTE

FTE 1.0

FLSA

FLSA Exempt

Scope of Job

To promote appropriate clinical documentation through collaboration with the School of Medicine clinical staff by reviewing patient documents, assessing for accuracy and educating the patient care team to ensure guidelines are met and appropriate process is followed.

Description of Duties

• Obtains and promotes appropriate clinical documentation through interaction with clinical staff and physicians to ensure documentation is complete, accurate and reflects the level of service rendered to patients.
• Conducts complex reviews of physician/provider billing compliance activities in accordance with applicable laws, regulations, rules or policies.
• Performs prospective and retrospective audits of documentation to confirm compliance with documentation and billing rules and government regulations. Provides feedback and education related to audit results.
• Reviews documentation by physicians and clinical staff as well as lab results, diagnostic information and treatment plans to assure accuracy.
• Reviews files to identify documentation gaps and requests clarification from physicians and other caregivers of unclear diagnoses, patient complications, procedures and clinical documentation.
• Works closely with Revenue Cycle billing/collection staff to ensure accurate physician reimbursement is achieved and claims denials are reduced by ensuring documentation integrity.
• Educates all members of the patient care team on documentation guidelines on an ongoing basis.
• Develops and presents on-going documentation education for staff including coders, physicians, residents, clinical staff, and allied health professionals.
• Prepares reports, provides supporting evidence and makes recommendations regarding identified documentation and coding deficiencies or gaps. Identifies trends and provides feedback to medical staff, coders, and management.
• Acts as a knowledge expert to service providers and coders through familiarity with coding conventions.
• Works closely with Revenue Cycle coding staff on Clinical Documentation Improvement ( CDI ) activities, processes, and procedures.
• Provides education for medical student and resident orientation/development and other times as necessary.
• Presents recommendations for quality management and processes improvement opportunities regarding workflow and or policies and procedures as necessary.
• Maintains a thorough understanding of CPT , ICD
  -10 CM, and HCPCS coding principles, and keeps current with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates.
• Maintains positive and open communication with physicians, management and Revenue Cycle team.
• Adheres to internal controls and reporting structure.
• Performs other duties as assigned.

Supervision Received

General supervision from assigned supervisor.

Supervision Given

Direct supervision of assigned staff.

Required Education

Bachelor’s degree in Nursing, Health Information Management or related field from an accredited University.

Preferred Education

None.

Licenses/Certifications

Certified Professional Coder ( CPC ) from American Academy Professional Coders ( AAPC ), or…