Hospital - CDI Specialist, Associate

UT Health San Antonio; San Antonio (TX); On-site; USD 65,000 - 85,000; Full time

Benefits offered by this job

Time Off

Holidays

Discounts

Job summary

UT Health San Antonio seeks a CDI Specialist Associate to review inpatient records, ensure documentation reflects diagnoses and treatments, and collaborate with providers and coding teams.

You will support education, mentor new specialists, and drive improvements in documentation quality while maintaining confidentiality in a hospital setting.

Qualifications

• Knowledge of coding and reporting guidelines.
• Knowledge of medical terminology, anatomy, physiology, and pharmacology.
• Knowledge of ICD-10-CM/PCS and DRG regulations.
• Ability to interpret data to improve documentation practices.
• Experience with medical records abstraction and coding is preferred.

Responsibilities

• Evaluate day-to-day documentation by medical staff and patient caregivers.
• Ensure accuracy of clinical information for severity of illness, risk of mortality, DRG and outcomes.
• Initiate compliant verbal and written queries for documentation clarification.
• Conduct follow-up reviews to ensure completeness and consistency of care level.
• Track and escalate HAC and HARM quality measures.
• Assist with clinical validation reviews related to denials and appeals.

Skills

Coding guidelines

Medical terminology

Anatomy & physiology

DRG regulations

Data interpretation

Communication

Remote/office adaptability

RN/RHIT/RHIA/CDIP/CCDS credential

Education

HS Diploma or GED

Clinical Experience

RN, RHIT, RHIA, CDIP, or CCDS

Tools

EPIC

3M encoder

Job description

Job Description

The Clinical Documentation Integrity (CDI) Specialist Associate provides support and expertise by assessing and reviewing inpatient medical records to ensure documentation reflects diagnosis and treatment. Collaborates with providers, patient caregivers, quality department, and medical coding to ensure appropriate DRG assignment. Facilitates modifications to the medical record documentation to accurately reflect the patient’s severity of illness, risk of mortality, and DRG. Supports and maintains UT Health San Antonio policies, protocols, and values. Works under the general supervision of the CDI Manager in a hospital setting.

Responsibilities

• Responsible for the day-to-day evaluation of documentation by medical staff and patient caregivers.
• Ensure the accuracy and completeness of clinical information used for reporting severity of illness, risk of mortality, DRG and hospital outcomes.
• Using expert clinical knowledge, initiate compliant and effective verbal and written queries for points of clarification of the documentation in the medical record.
• Conducts follow-up reviews of clinical documentation to ensure the completeness and consistency of the level of care provided to the patient.
• Tracks and escalates HAC and HARM quality measures.
• Assists with clinical validation reviews related to the denials and appeals process.
• Assists CDI supervisor with developing provider education strategies to promote complete, accurate, and comprehensive medical record documentation.
• Assists with mentoring or training new Clinical Documentation Integrity Specialists.
• Analyzes data and reports quality issues to CDI Supervisor.
• Supports meeting organizational unbilled goals for Accounts Receivable with uncoded accounts.
• Performs all aspects of daily work in a manner that contributes to and ensures an environment of strict confidentiality.
• Performs all other duties as assigned.

Qualifications

• Knowledge of Official Guidelines for coding and reporting.
• Knowledge of medical terminology, human anatomy, physiology and pharmacology.
• Knowledge of disease pathology.
• Knowledge of ICD-10-CM/PCS.
• Knowledge of DRG payor regulations, documentation opportunities, and clinical documentation requirements.
• Ability to interpret data in order to improve documentation practices.
• Knowledge of operating ordinary business equipment in a remote and office environment, such as computers, keyboards, and telephones.
• Ability to work effectively in and navigate between common office software, coding software, billing software, and abstracting systems. Knowledge of coding resources and demonstrated proficiency in using resources.
• Ability to troubleshoot basic technical issues in the remote and office environment.
• Ability to communicate effectively with providers and patient care givers.
• REQUIRED QUALIFICATIONS: RN, RHIT, RHIA, CDIP, or CCDS.

Education

HS Diploma or GED

Must have Clinical Experience

Required Skills

Some experience in medical records abstraction and coding in an acute care setting is required. EPIC and a 3M encoder software experience is preferred.

About Us

The University of Texas at San Antonio (UT San Antonio) is a nationally recognized, top-tier public research university that unites the power of higher education, biomedical discovery and healthcare within one visionary institution. As the third-largest research university in Texas and a Carnegie R1-designated institution, UT San Antonio is a model of access and excellence – advancing knowledge, social mobility and public health across South Texas and beyond. UT San Antonio serves approximately 42,000 students in 320 academic programs spanning science, engineering, medicine, health, liberal arts, AI, cybersecurity, business, education and more. With 17,000 faculty and staff, UT San Antonio has been recognized by Forbes as one of America’s Best Employers for Company Culture.

Benefits Overview

UT Health San Antonio offers an excellent benefits package for its employees. Employees who work at least 20 hours a week, with an appointment of at least 4.5 months, are eligible for benefits.

Medical

UT SELECT Medical insurance is offered free for employees and administered by Blue Cross and Blue Shield of Texas. Family members can be added to the plan through payroll deduction. Employees and their dependents can also receive discounted copays and coinsurance when using UT Health Physicians, a network of 800 premier physicians including more than 100 specialists. Employees receive $50,000 of group term life insurance and $50,000 of basic accidental death and dismemberment insurance for free, with options to purchase additional employee and dependent coverage for both at group rates.

Dental

Three dental insurance plan options are available for employees and their families through Delta Dental Insurance Company, two PPOs and one dental HMO plan. Both PPO plans allow employees to choose any licensed dentist.

Vision

Fully insured Vision Care benefits are offered by Superior Vision Services. Two vision plan options that offer either standard or enhanced vision benefits.

Disability

Employees can enroll in the Disability Insurance which provides income if a non-work related illness or injury prevents you from working.

FSAs

Employees can enroll in flexible spending accounts (FSAs) to set aside money from earnings before taxes for qualifying dependent day care expenses or out-of-pocket health care expenses.

Retirement

Employees are eligible for either the Teacher Retirement System (TRS) or the Optional Retirement Plan (ORP). TRS is a defined benefit retirement plan which UT Health matches employee contributions. ORP is for eligible faculty staff employees. Voluntary retirement programs are also available to invest before- or after-tax dollars with the choice of five quality retirement plan providers.

Time Off

• Front-loaded Paid Time Off: 128 to 208 hours (16 to 26 days) of Paid Time Off based on years of service, given at the start of each fiscal year. PTO may be prorated in year one based on date of hire.
• Extended Illness Bank: 8 hours (1 day) accrued per month which can be used for illness or injury after one day of Paid Time Off is taken.
• Paid Family Leave: Up to 240 hours (6 weeks) to care for a spouse, child, or parent after 6 months of consecutive employment.
• Holidays: 12 set paid holidays each year.

Discounts

Employees enjoy a range of discounts on services, tickets, and gym membership.

EEO Statement

UT Health San Antonio is an equal employment opportunity and affirmative action employer. It is our policy to promote and ensure equal employment opportunity for all individuals without regard to race, color, religion, sex, gender identity, national origin, age, sexual orientation, disability, or veteran status.