[Hiring] Clinical Document Integrity Specialist @UT Southwestern Medical Center

Role Description

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.

Qualifications

• 3 years acute care Hospital nursing experience, preferably in critical care (i.e. ED, Trauma, Critical Care Units) and Two (2) years of experience working in a Clinical Documentation Integrity program
• 5 years nursing experience in an acute care Hospital including Three (3) years in critical care (i.e. ED, Trauma, Critical Care Units)
• Bachelor's Degree in nursing, BSN (preferred)
• Experience working in a remote environment (preferred)

Requirements

• (RN) REGISTERED NURSE
• (CCDS) Cert Clinical Documentation obtained upon hire or within 6 months after eligibility requirements are met
• (CDIP) CERT DOCUMENTATION IMPROVEMENT PRACTICE obtained upon hire or within 6 months after eligibility requirements are met

Benefits

• 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

Job Duties

• Reviews 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.
• Communicates effectively (face-to-face) with Physicians, the Healthcare Team, and Multidisciplinary Teams to ensure accurate and complete documentation of all relevant diagnoses, procedures, and treatments. Provides education on clinical documentation opportunities to support acuity, quality, and coding.
• Initiates Physician Queries for clarification and specificity as appropriate, following established query guidelines for compliant queries. Performs follow-ups to ensure clarification was documented prior to discharge.
• Performs follow-up reviews and updates CDI/DRG worksheet to reflect changes in patient status, to verify the most appropriate Prin Dx and DRG and validate supporting documentation.
• Works collaboratively with the Coding and Quality Teams to ensure the clinical documentation fills the 'gaps' between clinical and coding language.
• Maintains an expert level of knowledge of CDI related practice and performance.
• Provide backup for other CDI Specialists as needed.
• Support the Quality Standards set by UTSW and the HIM Coding & CDI Department.
• Other duties as assigned.