CLINICAL DOCUMENTATION SPECIALIST

Position Information

Posting NumberSRGV9164

Working TitleCLINICAL DOCUMENTATION SPECIALIST

Number of Vacancies1

LocationHarlingen, Texas

DepartmentSchool of Medicine/ Revenue Cycle

FTE1.0

FLSAExempt

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 Certified Coding Specialist – P ( CCS – P) from the American Health Information Management Association ( AHIMA ), or Certified Professional Medical Auditor ( CPMA ), or,

At time of hire, Registered Health Information Technician ( RHIT ) from the American Health Information Management Association ( AHIMA ), or Registered Health Information Administrator ( RHIA ) from the American Health Information Management Association ( AHIMA ), or Current State of Texas Professional Nursing License (RN), and must obtain one of the coding certifications stated above ( CPC , CCS -P, CPMA ) within 6 months of employment.

Preferred:Certified Clinical Documentation Improvement Practitioner ( CDI ) from the American Health Information Management Association ( AHIMA ).

Required Experience

Five (5) years of clinical coding and/or nursing experience in an ambulatory setting or in an acute care facility. May substitute required degree with additional years of experience on a one-to-one basis.

Preferred Experience

Five years of clinical documentation experience in an acute care facility.

Equipment

Use of standard office equipment.

Working Conditions

Needs to be able to successfully perform all required duties. Office and patient care environment; some travel and weekend work is required. UTRGV is a distributed institution, which requires presence at multiple locations throughout the Rio Grande Valley.

Other

Has a good understanding of all clinical information systems and data flow across the continuum. Ability to communicate effectively, written and verbal. Tact, diplomacy, discretion, and confidentiality of medical information required in all matters.

Physical Capabilities

N/A

Employment CategoryFull-Time

Minimum SalaryCommensurate with Experience

Posted SalaryCommensurate with Experience

Position Available Date10/05/2025

Grant Funded PositionNo

If Yes, Provide Grant Expiration Date

Posting Detail Information

EEO Statement

It is the policy of The University of Texas Rio Grande Valley to promote and ensure equal employment opportunities for all individuals without regard to race, color, national origin, sex, age, religion, disability, sexual orientation, gender identity or expression, genetic information or protected veteran status. In accordance with the requirements of Title VII of the Civil Rights Act of 1964, the Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990, as amended, our University is committed to comply with all government requirements and ensures non-discrimination in its education programs and activities, including employment. We encourage women, minorities and differently abled persons to apply for employment positions of interest.

Special Instructions to Applicants

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 for detailed contact information.

Additional Information

UTRGV is a distributed location institution and working location is subject to change based on need.

All UTRGV employees are required to have a criminal background check ( CBC ). Incomplete applications will not be considered.

Substitutions to the above requirements must have prior approval from the VP of Human Resources.

Quick Link

Posting Supplemental Questions

Required fields are indicated with an asterisk (*).

• • Are you a current UTRGV employee?

• Yes

• No

• • Are you now, or previously, employed by The University of Texas System or any of its institutions?

• Yes - I currently am employed by the UT System or its institutions

• Yes - I have previously been employed by the UT System or its institutions

• No - I have never been employed by the UT System or its institutions

• • Please select your highest level of completed education.

• 6th grade education

• 10th grade education

• High School Diploma or GED

• Associates Degree, Technical, or Trade School Degree/Certification or 60 Hours of College Hours

• Bachelors Degree from an accredited university

• Masters Degree from an accredited university

• Ph. D. or other terminal degree from an accredited university

• None of the above

• • Please provide the field of study for your education:

(Open Ended Question)

• • Please indicate the number of years of work experience you have directly related to the position in which you are applying for:

• Less than 1 year

• 1 year

• 2 years

• 3 years

• 4 years

• 5 years

• 6 years

• 7 years

• 8 years

• 9 years

• 10 years

• Over 10 years

• • Do you meet the minimum requirements for this position?

• Yes

• No

Applicant Documents

Required Documents

• Resume

• Certifications and Licenses

Optional Documents

• Cover Letter/Letter of Application

• Curriculum Vitae

• Unofficial Transcripts

• Reference Letter 1

• Reference Letter 2

• Training Certificates

• Other Document

• List of 3 References

• Unofficial Transcripts 2

• Unofficial Transcripts 3

• Letter of Interest

• Unofficial Graduate Transcripts

• Additional Document