CDI Specialist – Clinical Documentation & DRG Optimization

Baylor Scott & White Health; Lansing (MI); On-site; USD 60,000 - 90,000; Full time

Benefits offered by this job

Health benefits

401(k) match

Tuition Reimbursement

PTO starting Day 1

Job summary

Baylor Scott & White Health is seeking a CDI Specialist to review patient records for completeness and accuracy, requesting physician clarification as needed. You will understand ICD-10, DRG implications, and work with physicians and HIM teams to optimize documentation.

Responsibilities include promoting documentation improvements, educating practitioners, and ensuring the quality of coding and related data used for reimbursement and reporting.

Qualifications

• Bachelor's degree in nursing or Health Information Management or Health Informatics.
• RN or RHIA certification is required.
• Requires one of these: CCS, CCDS, CCDOSCP, CCDS-O, CDIP, CPC.
• Nursing: 4 years of nursing experience or combination of inpatient coding with at least 2 years of CDI experience.
• HIM: 4 years of medical record review experience in inpatient coding/auditing or Quality, or Case Management, or CDI.
• Knowledge of ICD-10, complications/comorbid conditions, and how they affect DRG, SOI/ROM, and ROM.

Responsibilities

• Facilitates accurate, timely, and complete documentation of medical conditions and treatment in patient records.
• Performs review of records to ensure complete, accurate documentation; update working DRG when appropriate.
• Promotes and obtains documentation for clinical conditions or procedures to support severity of illness and complexity of care.
• Recommends proficient queries to practitioners about missing or unclear health record documentation; Escalates non-responses.
• Collaborates with Health Information Management coders and Clinical Documentation Improvement Specialists; reconciles documentation and coding opportunities.
• Work with interdisciplinary teams to validate accurate DRG assignments.
• Develops ongoing education about documentation opportunities for practitioners and HIM staff; focuses on SOI, ROM, CMI, reimbursement.
• Formulates and examines data to improve documentation practices.

Education

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

Job description

Baylor Scott & White Health is seeking a CDI Specialist to review patient records for completeness and accuracy, requesting physician clarification as needed. You will understand ICD-10, DRG implications, and work with physicians and HIM teams to optimize documentation.

Responsibilities include promoting documentation improvements, educating practitioners, and ensuring the quality of coding and related data used for reimbursement and reporting.