CDI Specialist II — Elevate Patient Documentation

Baylor Scott & White Health; Topeka (KS); On-site; USD 75,000 - 98,000; Full time

Benefits offered by this job

Health benefits

401(k) match up to 5%

Tuition reimbursement

PTO accrual from Day 1

Job summary

Baylor Scott & White Health is seeking a qualified CDI specialist to review and improve patient record documentation, ensuring accuracy for DRG assignments. The role requires an RN or RHIA with a Bachelor's in a relevant field and certifications such as CCS, CCDS, or CPC.

Collaboration with clinicians and HIM is essential to optimize documentation and reimbursement. The ideal candidate will have 4 years of nursing or CDI experience and strong ICD-10 knowledge, contributing to data quality and

Qualifications

• Bachelor's degree in nursing or Health Information Management or Health Informatics.
• RN or RHIA certification is required.
• One of CCS, CCDS, CCDOSCP, CCDS-O, CDIP, or CPC certifications.
• Nursing: 4 years of nursing experience or CDI experience with 2 years in inpatient coding.
• HIM: 4 years of medical record review experience in inpatient coding/auditing or related areas.
• Knowledge of ICD-10, complications/ comorbid conditions, and DRG implications.

Responsibilities

• Facilitates accurate, timely documentation of medical conditions in patient records.
• Reviews records to ensure complete documentation and updates DRG when needed.
• Promotes documentation for clinical conditions to support SOI, ROM, and CMI.
• Recommends proficient queries to practitioners and escalates non-responses for reconciliation.
• Collaborates with HIM coders and clinical teams; reconciles documentation opportunities.
• Develops ongoing education about documentation opportunities for practitioners and allied staff.
• Analyzes data to improve documentation practices and DRG impact.

Skills

Clinical documentation

Medical record review

Collaboration

ICD-10 knowledge

Education

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

Registered Nurse (RN) or RHIA

Certifications: CCS, CCDS, CCDOSCP, CCDS-O, CDIP, CPC

Job description

Baylor Scott & White Health is seeking a qualified CDI specialist to review and improve patient record documentation, ensuring accuracy for DRG assignments. The role requires an RN or RHIA with a Bachelor's in a relevant field and certifications such as CCS, CCDS, or CPC.

Collaboration with clinicians and HIM is essential to optimize documentation and reimbursement. The ideal candidate will have 4 years of nursing or CDI experience and strong ICD-10 knowledge, contributing to data quality and