CDI & Medical Records Excellence Specialist II

Baylor Scott & White Health; Austin (TX); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Immediate health and welfare benefits

401(k) matching up to 5%

Tuition reimbursement

PTO accrual from Day 1

Job summary

Baylor Scott & White Health seeks an experienced health information professional to perform patient record reviews ensuring complete, accurate documentation that supports hospitalization and treatment. You will present queries to physicians to clarify gaps and ensure proper coding and DRG assignments.

Required knowledge includes ICD-10, complications/ comorbid conditions, and how they impact DRG, severity of illness, and risk of mortality.

Qualifications

• Bachelor's degree in nursing or Health Information Management or Health Informatics.
• RN or RHIA certification is preferred.
• Knowledge of DRG/ROM/SOI impact on reimbursement.
• Strong communication with physicians and care teams.

Responsibilities

• Facilitates accurate, timely documentation of medical conditions and treatment in patient records.
• Performs review of records to ensure complete documentation and updates DRG as needed.
• Promotes documentation for clinical conditions or procedures to support SOI/ROM and reimbursement.
• Proposes queries to practitioners for missing or unclear information and escalates when needed.
• Collaborates with HIM coders and CDI specialists to reconcile documentation and coding opportunities.

Skills

Medical documentation

Query physicians

DRG knowledge

Care team collaboration

Education

Bachelor's degree in nursing or Health Information Management or Health Informatics

Tools

ICD-10 knowledge

Job description

Baylor Scott & White Health seeks an experienced health information professional to perform patient record reviews ensuring complete, accurate documentation that supports hospitalization and treatment. You will present queries to physicians to clarify gaps and ensure proper coding and DRG assignments.

Required knowledge includes ICD-10, complications/ comorbid conditions, and how they impact DRG, severity of illness, and risk of mortality.