Nutex Health
is a leading innovator in the emergency care industry, delivering high-quality, patient-centered services through a unique micro-hospital and freestanding emergency department model. Our teams bring deep expertise across clinical operations, facility development, staffing, and day-to-day care delivery. Nutex supports every stage of emergency care operationscreating an environment where skilled professionals can make a meaningful impact while growing their careers. SUMMARY
The Clinical Documentation Specialist is responsible for enhancing the quality and accuracy of medical records by collaborating with physicians and healthcare team members. This role is integral to ensuring accurate clinical documentation that impacts patient care, coding, reimbursement, and organizational reporting. The role ensures documentation reflects the true level of service, severity, and risk of mortality, facilitating accurate coding and data reporting. RESPONSIBILITIES Review inpatient admissions promptly to identify documentation gaps. Work closely with providers, case managers, and coders to improve documentation clarity and completeness. Understand the flow of health information from documentation to coding and billing. Utilize hospital systems for record review and identify clarification opportunities. Apply ICD-10 guidelines to determine appropriate MS-DRG assignments. Enter and update review findings, including MS-DRG and length of stay data. Communicate with physicians via discussions or formal queries to resolve documentation issues. Follow-up on queries to ensure clarity and proper documentation. Educate staff and physicians on documentation best practices. Support coding professionals by providing clinical context and clarification. Collaborate with HIM and coding teams to review complex cases and ensure data accuracy. Engage in ongoing professional development through workshops and conferences. Stay current with coding standards, compliance, and regulatory changes. Maintain positive communication with all stakeholders and adhere to organizational policies and standards. Conduct thorough clinical documentation reviews to ensure accuracy and compliance with healthcare regulations. Collaborate with healthcare providers to improve documentation practices and enhance patient care outcomes. Utilize EHR systems to maintain and update medical records while adhering to HIPAA guidelines. Analyze patient data for DRG assignment and support coding accuracy with knowledge of ICD-9 and CPT coding. Participate in training and education initiatives to promote best practices in clinical documentation improvement.
QUALIFICATIONS
At least 2 years of CDI experience Bachelor of Science in Nursing (BSN) CCDS or CDIP certification Registered Nurse (RN) with at least 4 years of inpatient and emergency medicine clinical experience Extensive knowledge of complex disease processes and broad clinical experience in inpatient and emergency settings Current RN license or RHIA/RHIT/CCS (medical school graduates exempt). Must obtain CCDS or CDIP certification within 3 years of hire.
BENEFITS
401(k) 401(k) matching Dental insurance Disability insurance Employee discount Health insurance Health savings account Life insurance Paid time off Vision insurance
EDUCATION
Bachelor's (Required)
EXPERIENCE
CDI: 2 years (Required) Inpatient & Emergency medicine: 4 years (Required)
LICENSE / CERTIFICATION
RN License (Required) CCDS (Preferred) RHIA (Preferred)RHIT (Preferred)
WORK LOCATION
In person JOB TYPE
Full-time #J-18808-Ljbffr
is a leading innovator in the emergency care industry, delivering high-quality, patient-centered services through a unique micro-hospital and freestanding emergency department model. Our teams bring deep expertise across clinical operations, facility development, staffing, and day-to-day care delivery. Nutex supports every stage of emergency care operationscreating an environment where skilled professionals can make a meaningful impact while growing their careers. SUMMARY
The Clinical Documentation Specialist is responsible for enhancing the quality and accuracy of medical records by collaborating with physicians and healthcare team members. This role is integral to ensuring accurate clinical documentation that impacts patient care, coding, reimbursement, and organizational reporting. The role ensures documentation reflects the true level of service, severity, and risk of mortality, facilitating accurate coding and data reporting. RESPONSIBILITIES Review inpatient admissions promptly to identify documentation gaps. Work closely with providers, case managers, and coders to improve documentation clarity and completeness. Understand the flow of health information from documentation to coding and billing. Utilize hospital systems for record review and identify clarification opportunities. Apply ICD-10 guidelines to determine appropriate MS-DRG assignments. Enter and update review findings, including MS-DRG and length of stay data. Communicate with physicians via discussions or formal queries to resolve documentation issues. Follow-up on queries to ensure clarity and proper documentation. Educate staff and physicians on documentation best practices. Support coding professionals by providing clinical context and clarification. Collaborate with HIM and coding teams to review complex cases and ensure data accuracy. Engage in ongoing professional development through workshops and conferences. Stay current with coding standards, compliance, and regulatory changes. Maintain positive communication with all stakeholders and adhere to organizational policies and standards. Conduct thorough clinical documentation reviews to ensure accuracy and compliance with healthcare regulations. Collaborate with healthcare providers to improve documentation practices and enhance patient care outcomes. Utilize EHR systems to maintain and update medical records while adhering to HIPAA guidelines. Analyze patient data for DRG assignment and support coding accuracy with knowledge of ICD-9 and CPT coding. Participate in training and education initiatives to promote best practices in clinical documentation improvement.
QUALIFICATIONS
At least 2 years of CDI experience Bachelor of Science in Nursing (BSN) CCDS or CDIP certification Registered Nurse (RN) with at least 4 years of inpatient and emergency medicine clinical experience Extensive knowledge of complex disease processes and broad clinical experience in inpatient and emergency settings Current RN license or RHIA/RHIT/CCS (medical school graduates exempt). Must obtain CCDS or CDIP certification within 3 years of hire.
BENEFITS
401(k) 401(k) matching Dental insurance Disability insurance Employee discount Health insurance Health savings account Life insurance Paid time off Vision insurance
EDUCATION
Bachelor's (Required)
EXPERIENCE
CDI: 2 years (Required) Inpatient & Emergency medicine: 4 years (Required)
LICENSE / CERTIFICATION
RN License (Required) CCDS (Preferred) RHIA (Preferred)RHIT (Preferred)
WORK LOCATION
In person JOB TYPE
Full-time #J-18808-Ljbffr