Clinical Documentation Specialist Keystone Innovative Staffing Solution LLC Southlake, TX Job Details Part-time $18 - $19 an hour 3 days ago Qualifications Anatomy knowledge Nursing home experience Hospice experience Hospice care Medical terminology Full Job Description Overview We are seeking a highly motivated and detail-oriented Clinical Documentation Specialist to join our dynamic healthcare team. In this vital role, you will serve as a key contributor to ensuring accurate, complete, and compliant clinical documentation across various care settings. Your expertise will support clinical teams in optimizing documentation practices and improving patient care records. This position offers an exciting opportunity to impact patient outcomes positively while working within a collaborative and innovative environment dedicated to excellence in healthcare delivery. Responsibilities Review and analyze medical records and documentation for completeness, accuracy, and compliance with regulatory standards such as NCQA, HIPAA, and Medicare requirements. Collaborate with physicians, nurses, case managers, and other healthcare professionals to clarify documentation discrepancies or gaps promptly. Utilize electronic health record (EHR) systems such as Epic, Cerner, Athenahealth, eClinicalWorks, and others to extract data and facilitate documentation improvement initiatives. Conduct utilization review and management activities to ensure appropriate level of care, including inpatient, outpatient, ICU, PICU, and specialty units like trauma centers or hospice care. Provide clinical support services by preparing and organizing documentation in accordance with the provider's instructions Assist in discharge planning documentation to ensure seamless transitions of care across inpatient and outpatient settings. Maintain thorough records of documentation reviews, audits, and compliance activities aligned with hospital standards and accreditation requirements. Skills Extensive knowledge of medical terminology, anatomy, physiology, and clinical workflows across inpatient and outpatient environments. Proficiency with EMR/EHR systems such as Epic, Cerner Millennium, Athenahealth or similar platforms. Strong understanding of managed care processes including Medicare policies, utilization review/management protocols, and NCQA standards. Experience with critical care units such as ICU or PICU; trauma centers; emergency medicine; or hospice settings is highly desirable. Familiarity with medical coding (ICD-9/10), CPT coding, DRGs, MDS assessments for skilled nursing facilities or nursing home experience preferred. Ability to interpret complex medical records accurately while ensuring compliance with HIPAA regulations. Excellent communication skills for collaborating with multidisciplinary teams and providing education on documentation best practices. Join us in this rewarding role where your expertise will directly influence the quality of patient care documentation while supporting operational excellence!

Pay:

$18.00 - $19.00 per hour

Work Location:

In person