Clinical Documentation Improvement Specialist

University Health; Pleasanton (TX); On-site; USD 70,000 - 100,000; Full time

Job summary

University Health is seeking a clinically competent RN with CDI experience to collaborate with the care team and review patient accounts for accurate documentation. You will query providers to ensure precise medical records and adhere to ACDIS/AHIMA guidelines to reflect ROM and SOI for optimal reimbursement.

The role requires knowledge of coding guidelines, ACDIS standards, Epic workflows, and 3M principles.

Qualifications

• Bachelor's degree in nursing preferred.
• Three years recent, full-time hospital experience preferred.
• Experience in documentation improvement or hospital quality assurance preferred.
• Must complete a Clinical Documentation Improvement Course within specified time of hire date.

Responsibilities

• Clinically competent in caring for the assigned inpatient population.
• Collaborate with the healthcare team.
• Review patient accounts for accurate and complete documentation of care.
• Query providers to ensure complete documentation in medical records.
• Adhere to ACDIS/AHIMA query guidelines for accurate documentation during hospital stay.
• Promote documentation reflecting ROM and SOI for maximum reimbursement.
• Maintain knowledge of coding guidelines, ACDIS standards, Epic workflows and 3M principles.

Skills

Clinical documentation improvement

Case management

Utilization review

Hospital quality assurance

Epic workflows

ACDIS standards

3M principles

Education

Bachelor's degree in Nursing

Tools

Epic workflows

3M principles

ACDIS standards

Utilization review software

Job description

University Health is seeking a clinically competent RN with CDI experience to collaborate with the care team and review patient accounts for accurate documentation. You will query providers to ensure precise medical records and adhere to ACDIS/AHIMA guidelines to reflect ROM and SOI for optimal reimbursement.

The role requires knowledge of coding guidelines, ACDIS standards, Epic workflows, and 3M principles.