CDI Specialist II: Documentation Excellence

Baylor Scott & White Health; Cheyenne (WY); On-site; USD 75,000 - 110,000; Full time

Benefits offered by this job

Immediate eligibility for health and w

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

Tuition Reimbursement

PTO accrual beginning Day 1

Job summary

Baylor Scott & White Health in Wyoming is seeking an experienced CDI Specialist (RN or RHIA) to review patient records for complete documentation and accurate DRG assignments. You will query physicians, ensure ICD-10 coding accuracy, and collaborate with HIM coders and clinicians to improve documentation quality.

The role requires nursing or health information management credentials, relevant certifications, and several years of inpatient coding/auditing experience; a patient-centered,

Qualifications

• Must have a Bachelor's degree in nursing or Health Information Management or Health Informatics.
• Must be a Registered Nurse (RN) or Registered Health Information Administrator (RHIA).
• Requires one of these certifications: CCS, CCDS, CCDOSCP, CCDS-O, CDIP, or CPC.

Responsibilities

• Facilitates accurate, timely documentation of medical conditions and treatment in patient records.
• Performs review of record to establish complete, accurate documentation and updates working DRG as needed.
• Promotes and obtains documentation for clinical conditions to support severity of illness, risk of mortality, and complexity of care.
• Demonstrates the ability to recommend proficient queries to practitioners or support staff about missing, unclear, or conflicting health record documentation.
• Collaborates with Health Information Management coders and Clinical Documentation Improvement Specialists and works with interdisciplinary teams.
• Collaboratively works with interdisciplinary teams to validate accurate DRG assignments.
• Develops and provides ongoing education about documentation opportunities to practitioners and staff; promotes related education.
• Formulates, interprets, 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 in Wyoming is seeking an experienced CDI Specialist (RN or RHIA) to review patient records for complete documentation and accurate DRG assignments. You will query physicians, ensure ICD-10 coding accuracy, and collaborate with HIM coders and clinicians to improve documentation quality.

The role requires nursing or health information management credentials, relevant certifications, and several years of inpatient coding/auditing experience; a patient-centered,