Clinical Documentation Improvement Specialist II

Baylor Scott & White Health; Dallas (TX); On-site; USD 85,000 - 105,000; Full time

Benefits offered by this job

Immediate eligibility for health and W

401(k) savings plan with dollar-for-dl

Tuition Reimbursement

PTO accrual beginning Day 1

Job summary

Baylor Scott & White Health in Texas is seeking a Clinical Documentation Specialist to ensure accurate, complete hospitalization records and to present queries to physicians for clarification. The role requires knowledge of ICD-10, DRG, severity of illness, and risk of mortality, with collaboration across physicians, coders and care teams to improve documentation and reimbursement.

This position emphasizes education, continuous improvement, and interdisciplinary teamwork within a large

Qualifications

• Bachelor's degree in nursing or Health Information Management/Health Informatics.
• Registered Nurse (RN) or Registered Health Information Administrator (RHIA).
• Certification credentials: CCS, CCDS, CCDOSCP, CCDS-O, CDIP, CPC.
• Nursing experience: 4 years, or CDI experience with 2+ years.
• HIM: 4 years of medical record review in inpatient coding/auditing or related fields.

Responsibilities

• Facilitates accurate, timely documentation of medical conditions and treatment in patient records.
• Performs record reviews and queries to clarify unclear or incomplete documentation.
• Collaborates with coders and CDI specialists to reconcile documentation and DRG assignments.
• Educates practitioners and staff on documentation improvements to impact SOI/ROM/CMI and reimbursement.
• Works with interdisciplinary teams to validate DRG assignments and improve data reporting.

Job description

Baylor Scott & White Health in Texas is seeking a Clinical Documentation Specialist to ensure accurate, complete hospitalization records and to present queries to physicians for clarification. The role requires knowledge of ICD-10, DRG, severity of illness, and risk of mortality, with collaboration across physicians, coders and care teams to improve documentation and reimbursement.

This position emphasizes education, continuous improvement, and interdisciplinary teamwork within a large