Clinical Document Integrity Specialist

Overview Clinical Document Integrity Specialist (958449) Job Summary The CDI Specialist facilitates appropriate clinical documentation reviews concurrently to ensure that the level of services and acuity of care are accurately reflected in the medical record to improve overall quality and completeness of clinical documentation. Communicates effectively with physicians and the healthcare team. Initiates provider queries as appropriate for documentation clarification and specificity. Benefits UT Southwestern offers a competitive and comprehensive benefits package to eligible employees designed to support overall wellbeing, including: PPO medical plan, available day one at no cost for full-time employee-only coverage 100% coverage for preventive healthcare – no copay Paid Time Off, available day one Retirement programs through the Teacher Retirement System of Texas (TRS) Paid Parental Leave Benefit Wellness programs Tuition Reimbursement Public Service Loan Forgiveness (PSLF) Qualified Employer Learn more about these and other UT Southwestern employee benefits Experience and Education Required Experience 3 years acute care hospital nursing experience, preferably in critical care (e.g., ED, Trauma, Critical Care Units) and two (2) years of experience working in a Clinical Documentation Integrity program, or 5 years nursing experience in an acute care hospital including three (3) years in critical care (e.g., ED, Trauma, Critical Care Units) Licenses and Certifications (RN) Registered Nurse and (CCDS) Certified Clinical Documentation Specialist obtained upon hire or within 6 months after eligibility requirements are met or (CDIP) Certified Documentation Improvement Professional obtained upon hire or within 6 months after eligibility requirements are met Preferred Education Bachelor’s Degree in Nursing, BSN Experience Experience working in a remote environment Job Duties Review patient records concurrently to ensure that the level of services and acuity of care are accurately reflected in the medical record to improve overall quality and completeness of clinical documentation. Communicate effectively with physicians, the healthcare team, and multidisciplinary teams to ensure accurate and complete documentation of all relevant diagnoses, procedures, and treatments. Provide education on clinical documentation opportunities to support acuity, quality, and coding. Initiate physician queries for clarification and specificity as appropriate, following established query guidelines for compliant queries. Perform follow-ups to ensure clarification was documented prior to discharge. Perform follow-up reviews and update CDI/DRG worksheets to reflect changes in patient status, verify the most appropriate principal diagnosis and DRG, and validate supporting documentation. Work collaboratively with Coding and Quality Teams to ensure clinical documentation fills the gaps between clinical and coding language. Maintain an expert level of knowledge of CDI-related practices and performance. Provide backup for other CDI Specialists as needed. Support the quality standards set by UT Southwestern and the HIM Coding & CDI Department. Other duties as assigned. Security and EEO Statement This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information. UT Southwestern Medical Center is committed to an equal opportunity workplace and prohibits unlawful discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status. UT Southwestern policy also prohibits discrimination on the basis of sexual orientation, gender identity, or gender expression. Copyright 2017. The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, Texas 75390. Phone View phone number on click.appcast.io #J-18808-Ljbffr The University of Texas Southwestern Medical Center