CDI Specialist II: Elevate Patient Documentation

Baylor Scott & White Health; Atlanta (GA); On-site; USD 85,000 - 105,000; Full time

Benefits offered by this job

Health benefits including medical and

401(k) matching up to 5%

Tuition Reimbursement

PTO accrual from Day 1

Job summary

Baylor Scott & White Health is seeking a Clinical Documentation Specialist to ensure complete, accurate documentation supporting hospitalization and treatment. You will query physicians for clarification and work with coding staff to optimize DRG and reimbursement outcomes.

The role requires strong knowledge of ICD-10, CC/CDI concepts, and collaboration with interdisciplinary teams to improve documentation quality and patient care data.

Qualifications

• Bachelor's degree in nursing or Health Information Management.
• RN or RHIA certification required.
• One of CCS, CCDS, CCDOSCP, CCDS-O, CDIP, or CPC certification.
• Nursing: 4 years experience or inpatient coding with at least 2 years CDI.
• HIM: 4 years in inpatient coding/auditing, quality, or CDI.
• Knowledge of ICD-10, complications/concomitant conditions, and DRG impact.

Responsibilities

• Facilitates accurate, timely documentation in patient records.
• Performs record review and updates DRG as needed.
• Promotes documentation for clinical conditions to support SOI, ROM, and reimbursement.
• Recommends proficient queries to practitioners for clarification.
• Collaborates with HIM coders, CDI specialists, and interdisciplinary teams.
• Validates accurate DRG assignments with the care team.
• Educates practitioners and staff on documentation opportunities and standards.
• Analyzes data to improve documentation practices and outcomes.

Skills

ICD-10 knowledge

Documentation improvement

Physician queries

Interdisciplinary collaboration

Education

Bachelor's degree in Nursing

Bachelor's degree in Health Information Management

Job description

Baylor Scott & White Health is seeking a Clinical Documentation Specialist to ensure complete, accurate documentation supporting hospitalization and treatment. You will query physicians for clarification and work with coding staff to optimize DRG and reimbursement outcomes.

The role requires strong knowledge of ICD-10, CC/CDI concepts, and collaboration with interdisciplinary teams to improve documentation quality and patient care data.