Clinical Doc Improvement Spec. II

BJC HealthCare; Missouri; On-site; USD 80,000 - 100,000; Full time

Benefits offered by this job

Comprehensive benefits

Tuition assistance

401(k) match

Paid time off

Job summary

BJC HealthCare in Missouri seeks a CDI Specialist II to join our clinical documentation improvement team. The role uses clinical and coding knowledge to review inpatient and outpatient records, ensuring documentation supports severity of illness, mortality risk, and care complexity.

You will engage providers, analyze data trends, and contribute to education programs and service-line improvements. The position requires nursing licensure (RN), 5–10 years of experience, and a Bachelor's in Nursing.

Qualifications

• RN licensure required or eligible.
• Minimum 5 years of clinical documentation improvement experience.
• Strong knowledge of inpatient and outpatient documentation, severity of illness and risk of mortality.

Responsibilities

• Actively engages providers to foster shared accountability for CDI and documentation improvement.
• Identify trends and variances using aggregated data to support the CDI program and proposal of solutions to leadership.
• Contributes to service line documentation improvement initiatives and provider education plans.
• Develops content for education and provider outreach, including scheduling and delivery for assigned service lines.
• Participates in organization projects related to documentation improvement.

Education

Nursing Diploma/Associate's

Bachelor's Degree - Nursing

Job description

Additional Information About the Role

BJC HealthCare is seeking a CDI Specialist II to join our team!

Overview

BJC HealthCare is one of the largest nonprofit health care organizations in the United States, delivering services to residents primarily in the greater St. Louis, southern Illinois and southeast Missouri regions. With net revenues of $6.3billion and more than 30,000 employees, BJC serves patients and their families in urban, suburban and rural communities through its 14hospitals and multiple community health locations. Services include inpatient and outpatient care, primary care, community health and wellness, workplace health, home health, community mental health, rehabilitation, long-term care and hospice.

BJC is the largest provider of charity care, unreimbursed care and community benefits in the state of Missouri. BJC and its hospitals and health service organizations provide $785.9 million annually in community benefit. That includes $410.6 million in charity care and other financial assistance to patients to ensure medical care regardless of their ability to pay. In addition, BJC provides additional community benefits through commitments to research, emergency preparedness, regional health care safety net services, health literacy, community outreach and community health programs and regional economic development.

BJC’s patients have access to the latest advances in medical science and technology through a formal affiliation between Barnes-Jewish Hospital and St. Louis Children’s Hospital with the renowned Washington University School of Medicine, which consistently ranks among the top medical schools in the country.

Preferred Qualifications

Role Purpose

The Clinical Documentation Improvement Specialist II (CDIS II) uses clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of both inpatient and outpatient medical records reviews to evaluate the clinical documentation of clinical services by identifying opportunities for improving the quality of medical record documentation. This position facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. This position also contributes to content development and provider education (formal and informal), contributes to ongoing service line documentation improvement initiatives, including formal and informal provider education plans, as well as participates in department and organization projects related to documentation improvement.

Responsibilities

• Actively engages providers and establish relationships to foster shared accountability related to CDI and documentation improvement efforts.
• Identifies trends, variances, deficiencies, and problems utilizing aggregated data and information as part of the integrated clinical documentation improvement program; performs provider and group level CDI data trend analysis, identifies issues and proposes solutions to leadership.
• Contributes to ongoing service line documentation improvement initiatives, including formal and informal provider education plans related to clinical documentation improvement. Participates in department and organization projects related to documentation improvement.
• Contributes to content development and potential presentation to key healthcare providers education resulting from the analysis of clinical and financial information from a variety of internal and external sources for the need of accurate and complete documentation in the medical record; interacts and participates in formal and informal education, including content creation, approval facilitation, meeting scheduling/frequency management, participation and possibly content delivery for all assigned service lines.
• Participates in department and organization projects related to documentation improvement.

Minimum Requirements

Education

• Nursing Diploma/Associate's
• - Nursing

Experience

• 5-10 years

Licenses & Certifications

• RN

Preferred Requirements

Education

• Bachelor's Degree
• - Nursing

Benefits and Legal Statement

BJC Total Rewards

• Comprehensive medical, dental, vison, life insurance, and legal services available first day of the month after hire date
• Disability insurance* paid for by BJC
• Annual 4% BJC Automatic Retirement Contribution
• 401(k) plan with BJC match
• Tuition Assistance available on first day
• BJC Institute for Learning and Development
• Health Care and Dependent Care Flexible Spending Accounts
• Paid Time Off benefit combines vacation, sick days, holidays and personal time
• Adoption assistance

To learn more, go to our Benefits Summary.

*Not all benefits apply to all jobs

The above information on this description has been designed to indicate the general nature and level of work performed by employees in this position. It is not designed to contain or be interpreted as an exhaustive list of all responsibilities, duties and qualifications required of employees assigned to this job. Equal Opportunity Employer