Baylor Scott & White Health
CDI Specialist III - Inpatient
Baylor Scott & White Health, Dallas, Texas, United States, 75215
CDI Specialist III - Inpatient
Registered Nurse (RN) position that performs patient record reviews to determine complete, accurate and timely documentation of all conditions that support hospitalization and treatment of the patient. Presents queries to physicians when needed to clarify ambiguous or incomplete documentation. Requires knowledge of ICD‑10, complications/comorbid conditions, and their role in the final Diagnosis Related Group, severity of illness, and risk of mortality.
Key Responsibilities
Facilitate accurate, timely, and complete documentation of medical conditions and treatment in patient records.
Review records to determine complete and accurate documentation of patient condition and treatment; update working DRG when appropriate.
Recommend proficient queries to practitioners or support staff regarding missing, unclear, or conflicting health record documentation; obtain additional documentation as needed.
Collaborate with Health Information Management coders, other Clinical Documentation Improvement Specialists and others to reconcile potential documentation and coding opportunities; analyze working versus final coded DRG.
Work collaboratively with interdisciplinary teams including physicians, mid‑level providers, nurses, patient safety staff and Health Information Improvement teams.
Develop and/or provide ongoing education and information regarding documentation opportunities to practitioners, Health Information Management Coders, and other Clinical Documentation Improvement Specialists.
Formulate, interpret, and analyze data relative to opportunities to improve documentation practices; prepare CDI metric‑based documents for senior leadership and medical staff groups/divisions.
Serve on internal hospital committees relating to CDI, CMI and ELOS; function as a subject matter expert and problem solver.
Work directly with physicians and act as liaison for physician and administrative meetings.
Train and audit BSWH CDI specialists.
Perform other position‑appropriate duties as required in a competent, professional and courteous manner.
Qualifications
Education: Master’s degree.
Experience: Minimum 5 years of experience in clinical documentation improvement or related field.
Certification/License/Registration: RN and one of the following coding certifications:
• Cert Cln Documentation Spec (CCDOSCP) or CCDSS
• Cert Cln Doc Spec Outpatient (CCDS‑O)
• Cert Coding Specialist (CCS)
• Cert Doc Improv Practitioner (CDIP)
• Cert Professional Coder (CPC)
• Reg Health Info Administrator (RHIA)
Clinical knowledge of disease process and medical record review skills.
Oral and written communication skills; one‑to‑one with providers.
Ability to present information to a group.
Must be RN or Registered Health Information Administrator (RHIA).
Benefits
Immediate eligibility for health and welfare benefits.
401(k) savings plan with dollar‑for‑dollar match up to 5%.
Tuition reimbursement.
PTO accrual beginning Day 1.
Note: Benefits may vary based on position type and/or level.
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Key Responsibilities
Facilitate accurate, timely, and complete documentation of medical conditions and treatment in patient records.
Review records to determine complete and accurate documentation of patient condition and treatment; update working DRG when appropriate.
Recommend proficient queries to practitioners or support staff regarding missing, unclear, or conflicting health record documentation; obtain additional documentation as needed.
Collaborate with Health Information Management coders, other Clinical Documentation Improvement Specialists and others to reconcile potential documentation and coding opportunities; analyze working versus final coded DRG.
Work collaboratively with interdisciplinary teams including physicians, mid‑level providers, nurses, patient safety staff and Health Information Improvement teams.
Develop and/or provide ongoing education and information regarding documentation opportunities to practitioners, Health Information Management Coders, and other Clinical Documentation Improvement Specialists.
Formulate, interpret, and analyze data relative to opportunities to improve documentation practices; prepare CDI metric‑based documents for senior leadership and medical staff groups/divisions.
Serve on internal hospital committees relating to CDI, CMI and ELOS; function as a subject matter expert and problem solver.
Work directly with physicians and act as liaison for physician and administrative meetings.
Train and audit BSWH CDI specialists.
Perform other position‑appropriate duties as required in a competent, professional and courteous manner.
Qualifications
Education: Master’s degree.
Experience: Minimum 5 years of experience in clinical documentation improvement or related field.
Certification/License/Registration: RN and one of the following coding certifications:
• Cert Cln Documentation Spec (CCDOSCP) or CCDSS
• Cert Cln Doc Spec Outpatient (CCDS‑O)
• Cert Coding Specialist (CCS)
• Cert Doc Improv Practitioner (CDIP)
• Cert Professional Coder (CPC)
• Reg Health Info Administrator (RHIA)
Clinical knowledge of disease process and medical record review skills.
Oral and written communication skills; one‑to‑one with providers.
Ability to present information to a group.
Must be RN or Registered Health Information Administrator (RHIA).
Benefits
Immediate eligibility for health and welfare benefits.
401(k) savings plan with dollar‑for‑dollar match up to 5%.
Tuition reimbursement.
PTO accrual beginning Day 1.
Note: Benefits may vary based on position type and/or level.
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