Documentation Improvement Coordinator

University Health; Hondo (TX); On-site; USD 70,000 - 95,000; Full time

Job summary

University Health in Texas seeks a Clinical Documentation Improvement (CDI) Specialist to ensure accurate inpatient documentation and maximize reimbursement. You will query providers and collaborate with the care team, while upholding coding guidelines, ACDIS standards, Epic workflows, and 3M principles.

Required is a Bachelor’s degree in Nursing with Texas RN licensure; 3+ years hospital experience preferred.

Qualifications

• Bachelor's degree in Nursing from an accredited college or university is preferred.
• Three years recent, full-time hospital experience preferred.
• Completion of a Clinical Documentation Improvement Course within specified time of hire.

Responsibilities

• Review patient documentation for accuracy and completeness.
• Query the provider to ensure documentation is recorded in the medical record.
• Promote documentation reflecting ROM and SOI for maximum reimbursement.
• Collaborate with the healthcare team while maintaining coding guideline knowledge.

Skills

Coding guidelines knowledge

ACDIS standards

Epic workflows

3M principles

Education

Bachelor's degree in Nursing

Tools

Clinical Documentation Improvement Course

Job description

POSITION SUMMARY/RESPONSIBILITIES:

Must be clinically competent in caring for the assigned inpatient population. Must work collaboratively with all members of the healthcare team. Reviews patient accounts through the appropriate review process for accurate and complete documentation of the care of the patient. Queries the provider to ensure that the accurate and complete documentation is recorded in the medical record. Concurrently reviews the documentation of the patients care and queries as appropriate following the ACDIS/AHIMA query brief guidelines to ensure complete and accurate documentation of a patient's care during their stay in the hospital. Promotes accurate documentation that reflects the appropriate risk of mortality (ROM) and severity of illness (SOI) resulting in maximum reimbursement. Maintains a strong understanding and knowledge of coding guidelines, ACDIS standards, Epic workflows, and 3M principles.

EDUCATION/EXPERIENCE

Graduation from an accredited college or university with a bachelor's degree in nursing is preferred. Three years recent, full-time hospital experience preferred. Work experience in documentation improvement, case management, utilization review or hospital quality assurance is preferred. Must complete a Clinical Documentation Improvement Course within specified time of hire date.

LICENSURE/CERTIFICATION

Current license from the Board of Nurse Examiners of the State of Texas to practice as a registered nurse; National certification (e.g. CDS, CCRN, RNC, CEN, CNOR, OCN, ANCC, CAN, CPAN, CFRN, etc.) in related field is preferred.