Clinical Documentation Improvement Specialist RN

Medical Center Health System; Odessa (TX); On-site; USD 70,000 - 95,000; Full time

Job summary

Medical Center Health System in Texas is seeking a Clinical Documentation Improvement Specialist RN to join our full-time day shift team. This role focuses on enhancing clinical documentation to support severity of illness, risk of mortality, and appropriate reimbursement, while ensuring accurate reporting of outcomes.

The CDI RN will query physicians to obtain precise documentation, educate care teams, and stay current with CMS rules and coding concepts.

Qualifications

• Minimum 1 year of clinical experience in acute care or related setting.
• Ability to read and analyze medical records and supporting documentation.
• Willingness to learn CMS rules and coding structures.
• Excellent written and verbal communication skills.

Responsibilities

• Facilitates improvement of clinical documentation.
• Obtains physician documentation to support severity of illness and reimbursement.
• Supports timely, accurate, and complete documentation for outcomes reporting.
• Educates all members of the patient care team on an ongoing basis.

Skills

Inpatient experience

Excellent communication

Critical thinking

Adaptability to CMS changes

Education

RN license in Texas

Tools

CMS coding guidelines

Job description

Clinical Documentation Improvement Specialist RN

Clinical Documentation Improvement

Full Time

Day Shift

M-F 8-4

Position Summary:

Facilitates improvement of clinical documentation. Obtains, through the query process, appropriate physician documentation that identifies clinical conditions or procedures and supports the severity of illness, risk of mortality, complexity of care, and appropriate reimbursement for the level of services rendered. Supports timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. Educates all members of the patient care team on an ongoing basis.

Qualifications:

Inpatient experience or other applicable clinical experience with excellent written and oral communication skills as well as critical thinking skills. Clinical knowledge (anatomy and physiology, pathophysiology, and pharmacology) and working knowledge of or ability to learn inpatient admission criteria. Knowledge of or ability to learn coding concepts and guidelines and clinical terminology, ability to read and analyze all information in a patient’s health record. This position will require assertive personality traits to facilitate ongoing physician communication and ability to establish and maintain strong verbal and written communication with providers and other clinicians. Requires computer literacy and familiarity with the operation of basic office equipment. Does require the ability to stand and walk in the performance of job responsibilities and to work independently in a time-oriented environment. Must have ability and willingness to seek out and accept change, demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice. A working knowledge of Medicare reimbursement system and coding structures preferred, but not required.

Education:

Current RN, LVN or other applicable license in the state of Texas.

Training and Experience:

Minimum of 1 year of clinical experience in acute care hospital setting or other clinical care setting (e.g., medical-surgical, ICU, case management, etc.). Familiar with or ability to learn documentation guidelines required for coding and revenue cycle processes. Excellent observation skills, analytical/critical thinking, problem-solving, plus effective verbal and written communication skills.

Job Knowledge:

Must have knowledge of health care delivery documentation systems and related medical record documents, knowledge of age-specific needs and the elements of disease processes and related procedures, as well as strong broad-based clinical knowledge and understanding of pathology/physiology. Excellent written and verbal communication skills and critical thinking skills and ability to work independently in a timeoriented environment. Working knowledge of inpatient admission criteria. Working knowledge of Medicare reimbursement system and coding structures preferred, but not required. Assertive personality traits to Page 5 of 5 facilitate ongoing physician communication. Keeps abreast of new theories and advances in coding practices. This position will require substantial interaction with Revenue Cycle billing, UOM and HIM coding functions at MCHS. Computer literacy and familiarity with the operation of basic office equipment is a must.

Unusual Physical Demands and Working Conditions:

A. Must be able to work at a computer for hours at a time and be able to juggle job duties to meet deadlines.

B. Ability to stand and walk in the performance of job responsibilities

C. Must have ability to remain calm, to think and act quickly and logically in a crisis. D. Must be able to work independently, with the possibility of frequent interruptions. Must be able to work independently, with the possibility of frequent interruptions.