Clinical Documentation Improvement (CDI) Specialist

University of Texas Rio Grande Valley; Edinburg (TX); On-site; USD 70,000 - 95,000; Full time

Job summary

The University of Texas Rio Grande Valley seeks a Clinical Documentation Specialist to promote accurate clinical documentation by reviewing patient records and educating the care team to ensure documentation reflects the level of service rendered.

You will conduct complex reviews and audits of physician billing, identify documentation gaps, and provide feedback to clinicians and revenue cycle staff to improve reimbursement and compliance with CPT, ICD-10-CM, and HCPCS coding guidelines.

Qualifications

• Bachelor's degree in Nursing, Health Information Management or related field from an accredited university.
• Five years of clinical coding and/or nursing experience preferred.
• Certified Professional Coder (CPC) or CCS-P/CPMA certification preferred.

Responsibilities

• Obtains and promotes appropriate clinical documentation through interaction with clinical staff and physicians to ensure documentation is complete and reflects the level of service rendered.
• Conducts complex reviews of physician/provider billing compliance activities in accordance with applicable laws, regulations, rules or policies.
• Performs prospective and retrospective audits of documentation to confirm compliance with documentation and coding rules and government regulations; provides feedback and education related to audit results.

Skills

Clinical documentation

Auditing

Education/training

Education

Bachelor's degree in Nursing or Health Information Management

Job description

The University of Texas Rio Grande Valley seeks a Clinical Documentation Specialist to promote accurate clinical documentation by reviewing patient records and educating the care team to ensure documentation reflects the level of service rendered.

You will conduct complex reviews and audits of physician billing, identify documentation gaps, and provide feedback to clinicians and revenue cycle staff to improve reimbursement and compliance with CPT, ICD-10-CM, and HCPCS coding guidelines.