CDI Specialist II — Elevate Patient Documentation

Baylor Scott & White Health; Austin (TX); On-site; USD 85,000 - 110,000; Full time

Benefits offered by this job

Health benefits

401(k) match

Tuition reimbursement

PTO day 1

Job summary

Baylor Scott & White Health in Austin, TX seeks a Clinical Documentation Improvement Specialist to ensure complete, accurate, and timely documentation supporting hospitalization and treatment.

You will query physicians, collaborate with Health Information Management coders and CDI specialists, and educate practitioners on documentation practices to improve DRG, SOI, ROM, reimbursement, and patient data quality.

Qualifications

• Bachelor's degree in nursing or Health Information Management or Health Informatics.
• RN or RHIA certification required.
• Certifications such as CCS, CCDS, CCDOSCP, CCDS-O, CDIP, or CPC required.
• Nursing: 4 years of nursing experience or inpatient coding with at least 2 years CDI.
• HIM: 4 years of medical record review in inpatient coding/auditing/Quality/Case Management/CDI.

Responsibilities

• Facilitates complete, accurate documentation of medical conditions and treatment in patient records.
• Performs record review to ensure complete documentation and update working DRG as needed.
• Promotes documentation for clinical conditions to support SOI, ROM, and reimbursement.
• Recommends proficient queries to practitioners about missing or unclear documentation; escalates as needed.
• Collaborates with HIM coders and CDI Specialists; works with interdisciplinary teams to reconcile coding opportunities.
• Validates accurate DRG assignments with interdisciplinary teams.

Skills

Medical coding

Clinical documentation

Interdisciplinary teamwork

Education

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

Job description

Baylor Scott & White Health in Austin, TX seeks a Clinical Documentation Improvement Specialist to ensure complete, accurate, and timely documentation supporting hospitalization and treatment.

You will query physicians, collaborate with Health Information Management coders and CDI specialists, and educate practitioners on documentation practices to improve DRG, SOI, ROM, reimbursement, and patient data quality.