CDI Specialist II — Clinical Documentation Improvement

Baylor Scott & White Health; Santa Fe (NM); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Immediate eligibility for health and w

401(k) savings plan with dollar-for-d

Tuition Reimbursement

PTO accrual beginning Day 1

Job summary

Baylor Scott & White Health in Santa Fe, NM seeks a Clinical Documentation Specialist who will perform patient record reviews to ensure complete and accurate documentation supporting hospitalization and treatment. You will query physicians to clarify unclear documentation and work with HIM coders to optimize DRG assignments.

The role requires a Bachelor’s degree in nursing or health information management, RN or RHIA certification, and CDI/medical-record review experience with ICD-10 knowledge.

Qualifications

• Bachelor’s degree in nursing or Health Information Management or Health Informatics.
• RN or RHIA certification required; one of CCS, CCDS, CCDOSCP, CCDS-O, CDIP or CPC preferred.
• 4 years nursing experience or 4 years medical record review experience in inpatient coding/auditing or CDI.

Responsibilities

• Facilitates accurate, timely, and complete documentation in patient records.
• Performs review of records to ensure complete documentation and updates DRG when appropriate.
• Collaborates with clinicians and HIM coders to improve documentation and coding opportunities.
• Develops and provides ongoing education about documentation opportunities to practitioners and teams.

Skills

Documentation review

DRG coding

Query physicians

Interdisciplinary collaboration

Education

Bachelor's degree in Nursing/Health Information Management/Health Informatics

Job description

Baylor Scott & White Health in Santa Fe, NM seeks a Clinical Documentation Specialist who will perform patient record reviews to ensure complete and accurate documentation supporting hospitalization and treatment. You will query physicians to clarify unclear documentation and work with HIM coders to optimize DRG assignments.

The role requires a Bachelor’s degree in nursing or health information management, RN or RHIA certification, and CDI/medical-record review experience with ICD-10 knowledge.