The University of Texas Medical Branch Clinical Documentation/Coding Specialist - Clinical Data Management (Galveston) in Galveston, Texas

Min Qualifications

  • RN, RHIA/RHIT, CCS, CCDS or Associates Degree in medical field; five (5) years’ experience in acute care (Med-Surg) inpatient hospital setting performing coding or clinical documentation improvement.
  • ICD-10 CM +PCS certified or able to obtain certification within 6 months of hire date


Responsible for the overall improvement of the quality, completeness and accuracy of medical record documentation through interaction with physicians and other members of the patient care team and hospital coding staff. Ensures clinical documentation reflects the level of service, severity of illness, risk of mortality and is complete and accurate. Successfully facilitates the accurate representation of a patient’s status that translates into coded data.

Salary Range

The salary range for this position is from $60,240 to $90,360 annually, commensurate with experience.

This position is a pay Band Code CS21.

Specific Job Related Duties

  • Concurrently reviews inpatient admissions to identify opportunities to improve the quality of documentation.
  • Applies knowledge of inpatient ICD-9 & 10 coding guidelines and clinical documentation requirements to assign working MS-DRG.
  • Enters review information and working MS DRG with associated length of stay in 3M shared information system and updates this information as needed to reflect any changes in patient’s status, procedure and treatments.
  • Communicates, educates, monitors and reports clinical documentation opportunities in various hospital venues.
  • Complies with all relevant policies, procedures, guidelines and other regulatory, compliance and accreditation standards
  • Initiates physician interaction to clarify ambiguous or conflicting documentation, and assure any clarification is noted in the patient record according to physician query policy.
  • Provides education regarding compliant documentation to physicians.
  • Assumes responsibility for professional development by participating in workshops, conferences and/ or in-services.
  • Relates the importance of complete documentation on coding quality, DRG assignment, physician profiling, case mix index and expected mortality rates.
  • May be called on to present to large and/ or small groups of executives, physicians and other clinical or financial personnel.
  • Keeps current with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates.
  • Understands the general flow of health information from medical record documentation and discharge, through coding, to billing and finally to data reporting.
  • Demonstrates excellent observation skills, analytical thinking and problem solving plus good verbal and written communication.
  • Utilizes organization, time management, prioritization skills and the ability to multitask.
  • Interacts with clinical staff in an assertive yet even tempered and personable demeanor.
  • Easily communicates with others in a variety of settings and circumstances both one-on-one and in small or large groups.
  • Maintains positive and open communication with physicians, members of the patient care team, case management and hospital coding staff.
  • Has a good understanding of all clinical information systems and data flow across the continuum.
  • Adheres to internal controls and reporting structure.

Preferred Work Experience

Our ideal candidate is -

  • RN with RHIA/RHIT, CCS or CCDS
  • 5 years experience in acute care (Med-Surg) inpatient hospital setting performing coding or clinical documentation improvement.

Closing Statement

#top #Nurse #Prof #admin

Equal Employment Opportunity

UTMB Health strives to provide equal opportunity employment without regard to race, color, national origin, sex, age, religion, disability, sexual orientation, gender identity or expression, genetic information or veteran status. As a VEVRAA Federal Contractor, UTMB Health takes affirmative action to hire and advance women, minorities, protected veterans and individuals with disabilities.

Full/Part Time: Full-Time

Regular/Temporary: Regular

Job Title: Clinical Documentation/Coding Specialist - Clinical Data Management (Galveston)

Job ID: 56220

Location: Galveston

Business Unit: HOSPT