Clinical Documentation Improvement Specialist

Baylor Scott & White Health; Indianapolis (IN); On-site; USD 70,000 - 100,000; Full time

Job summary

Baylor Scott & White Health in Indianapolis is seeking a Clinical Documentation Improvement Specialist to ensure accurate documentation for hospitalizations. You will collaborate with physicians, coders, and case management to optimize DRG accuracy and reimbursement.

The role requires RN or RHIA credentials, CDI or coding experience, and a strong knowledge of ICD-10 and documentation best practices. We offer professional growth and a commitment to quality care.

Qualifications

• Bachelor's degree in nursing, HIM, or health informatics.
• RN or RHIA certification.
• One of these certifications: CCS, CCDS, CCDOSCP, CCDS-O, CDIP, or CPC.
• 4 years of nursing experience or 2+ years of inpatient CDI with coding.
• HIM: 4 years in inpatient coding/auditing, Quality, Case Management, or CDI.
• Knowledge of ICD-10, complications/comorbid conditions, DRG, SOI/ROM.

Responsibilities

• Facilitates accurate documentation of medical conditions and treatments in patient records.
• Reviews records to ensure complete, accurate documentation of patient condition and treatment; update DRG as needed.
• Promotes documentation for clinical conditions or procedures to support SOI/ROM and reimbursement.
• Recommends queries to practitioners for missing or unclear documentation; escalates non-responses as needed.
• Collaborates with HIM coders and Clinical Documentation Improvement Specialists across teams.
• Develops education on documentation opportunities for practitioners and allied staff.

Skills

Nursing experience

CDI experience

Education

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

Job description

Baylor Scott & White Health in Indianapolis is seeking a Clinical Documentation Improvement Specialist to ensure accurate documentation for hospitalizations. You will collaborate with physicians, coders, and case management to optimize DRG accuracy and reimbursement.

The role requires RN or RHIA credentials, CDI or coding experience, and a strong knowledge of ICD-10 and documentation best practices. We offer professional growth and a commitment to quality care.