Clinical Documentation Improvement Specialist

Baylor Scott & White Health; Jefferson City (MO); On-site; USD 70,000 - 100,000; Full time

Benefits offered by this job

Health benefits

401(k) matching up to 5%

Tuition Reimbursement

PTO accrual Day 1

Job summary

Baylor Scott & White Health in Missouri is seeking a Clinical Documentation Improvement Specialist to ensure complete and accurate patient records and DRG assignments. You will educate practitioners and collaborate with coders and clinical staff to optimize documentation.

Qualifications include RN or RHIA with CDI certifications; a nursing or HIM degree; and several years of inpatient record review and documentation improvement experience.

Qualifications

• Bachelor's degree required in nursing, HIM, or health informatics.
• RN or RHIA certification required.
• One of CCS, CCDS, CCDOSCP, CCDS-O, CDIP, or CPC certification required.
• Nursing: 4 years of nursing experience or 2+ CDI experience.
• HIM: 4 years of medical record review in inpatient coding/auditing.

Responsibilities

• Facilitates accurate, timely, and complete documentation of medical conditions and treatment in patient records.
• Reviews records to ensure complete documentation and updates DRG as needed.
• Promotes documentation for clinical conditions or procedures to support SOI, ROM, and DRG.
• Formulates queries to practitioners for missing or unclear documentation and escalates unresolved cases.
• Collaborates with HIM coders and CDI specialists and works with interdisciplinary teams to validate accurate DRG assignments.
• Develops education on documentation opportunities for practitioners and allied health professionals.

Skills

Clinical documentation

DRG knowledge

Interdisciplinary collaboration

Education delivery

Education

Bachelor's degree in nursing, HIM, or Health Informatics

Job description

Baylor Scott & White Health in Missouri is seeking a Clinical Documentation Improvement Specialist to ensure complete and accurate patient records and DRG assignments. You will educate practitioners and collaborate with coders and clinical staff to optimize documentation.

Qualifications include RN or RHIA with CDI certifications; a nursing or HIM degree; and several years of inpatient record review and documentation improvement experience.