CDI Specialist: Elevate Documentation & DRG Quality

Baylor Scott & White Health; United States; On-site; USD 80,000 - 110,000; Full time

Benefits offered by this job

Health benefits and welfare coverage

401(k) with 5% match

Tuition reimbursement

PTO from Day 1

Job summary

Baylor Scott & White Health is seeking a CDI-focused professional to ensure complete and accurate documentation in patient records, and to query physicians when needed to clarify information. You will work with interdisciplinary teams to improve DRG assignments and overall chart quality.

Requirements include an RN or RHIA credential, a relevant bachelor's degree, and CDI/medical record review experience. Certification in CCS/CCDS/CDS-O/CDIP/CPC is expected.

Qualifications

• Bachelor's degree in nursing or Health Information Management or Health Informatics.
• Must be a Registered Nurse (RN) or Registered Health Information Administrator (RHIA).
• Certifications: CCS, CCDS, CCDOSCP, CCDS-O, CDIP or CPC required.
• Nursing: 4 years of nursing experience or 2 years of inpatient CDI experience.
• HIM: 4 years of medical record review experience in inpatient coding/auditing or CDI.

Responsibilities

• Facilitates accurate, timely, and complete documentation of medical conditions and treatment in patient records.
• Reviews records to ensure complete documentation and update working DRG as needed.
• Promotes documentation for clinical conditions or procedures to support SOI, ROM, CMI, reimbursement.
• Recommends proficient queries to practitioners for missing or unclear documentation.
• Collaborates with HIM coders and CDI specialists and with interdisciplinary teams.

Skills

DRG accuracy

ICD-10 knowledge

Documentation improvement

Interdisciplinary collaboration

Education

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

Tools

Health Information Management systems

Job description

Baylor Scott & White Health is seeking a CDI-focused professional to ensure complete and accurate documentation in patient records, and to query physicians when needed to clarify information. You will work with interdisciplinary teams to improve DRG assignments and overall chart quality.

Requirements include an RN or RHIA credential, a relevant bachelor's degree, and CDI/medical record review experience. Certification in CCS/CCDS/CDS-O/CDIP/CPC is expected.