Clinical Documentation Improvement Specialist

Baylor Scott & White Health; Oklahoma City (OK); On-site; USD 90,000 - 120,000; Full time

Job summary

Baylor Scott & White Health in the United States seeks a CDI specialist to ensure complete documentation for accurate DRG assignments. You will collaborate with physicians and HIM/CDI teams to improve coding quality and reimbursement while supporting patient care documentation.

Required are a nursing or HIM degree and appropriate certifications; RN or RHIA status; extensive CDI experience and strong knowledge of ICD-10 and related DRG concepts. Equal opportunity employer.

Qualifications

• Bachelor's degree in nursing or Health Information Management or Health Informatics.
• RN or RHIA certification required.
• One of these certifications CCS, CCDS, CCDOSCP, CCDS-O, CDIP, or CPC.
• Nursing: 4 years of nursing experience or a combination with at least 2 years of CDI experience.
• HIM: 4 years of medical record review experience in inpatient coding/auditing or Quality, Case Management, or CDI.

Responsibilities

• Facilitates accurate, timely, and complete documentation of medical conditions and treatment in patient records.
• Performs review of records to establish complete documentation and update working DRG when appropriate.
• Promotes documentation for clinical conditions or procedures to support DRG, SOI, ROM, and reimbursement.
• Interacts with practitioners to formulate proficient queries and escalates non-responses.
• Collaborates with Health Information Management coders and CDI Specialists; works with interdisciplinary teams.
• Validates accurate DRG assignments with teams.
• Develops and provides ongoing education about documentation opportunities to practitioners and staff.
• Analyzes data to improve documentation practices and DRG impact.

Skills

Nursing experience

Medical coding knowledge

Documentation improvement

Education

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

Tools

CCS

CCDS

CCDS-O

CDIP

CPC

RHIA

RN

Job description

Baylor Scott & White Health in the United States seeks a CDI specialist to ensure complete documentation for accurate DRG assignments. You will collaborate with physicians and HIM/CDI teams to improve coding quality and reimbursement while supporting patient care documentation.

Required are a nursing or HIM degree and appropriate certifications; RN or RHIA status; extensive CDI experience and strong knowledge of ICD-10 and related DRG concepts. Equal opportunity employer.