Senior CDI & DRG Optimization Specialist

Baylor Scott & White Health; Hartford (CT); On-site; USD 75,000 - 105,000; Full time

Benefits offered by this job

Health benefits

Tuition reimbursement

PTO accrual Day 1

Job summary

Baylor Scott & White Health seeks a qualified Clinical Documentation Improvement professional to ensure complete and accurate medical record documentation for hospitalization and treatment. You will query physicians for clarification, know ICD-10 coding, DRG impact, and collaborate with CDI specialists and interdisciplinary teams.

Role focuses on improving documentation quality, SOI/ROM, and reimbursement through education and proactive documentation reviews.

Qualifications

• Bachelor's degree in nursing or Health Information Management (HIM)
• RN or RHIA certification required
• 4 years of nursing experience or 2 years of CDI in inpatient coding
• HIM: 4 years of medical record review in inpatient coding/auditing or related fields
• Know ICD-10, complications/comorbid conditions, and how they affect DRG, SOI/ROM, and ROM

Responsibilities

• Facilitates accurate, timely, and complete documentation of medical conditions in patient records.
• Performs review of records to ensure complete documentation and updates DRG when appropriate.
• Promotes documentation for clinical conditions to support severity of illness and risk of mortality.
• Recommends proficient queries to practitioners or staff for missing or unclear documentation.
• Collaborates with coders and CDI specialists to reconcile documentation and coding opportunities.
• Works with interdisciplinary teams to validate accurate DRG assignments.
• Develops ongoing education about documentation opportunities for practitioners and HIM staff.
• Analyzes data to improve documentation practices and related outcomes.

Skills

Clinical documentation practice

DRG terminology

Interdisciplinary collaboration

Healthcare coding

RN/RHIA credentials

Education

Bachelor's degree in nursing

Bachelor's degree in Health Information Management

Tools

Coding software

Job description

Baylor Scott & White Health seeks a qualified Clinical Documentation Improvement professional to ensure complete and accurate medical record documentation for hospitalization and treatment. You will query physicians for clarification, know ICD-10 coding, DRG impact, and collaborate with CDI specialists and interdisciplinary teams.

Role focuses on improving documentation quality, SOI/ROM, and reimbursement through education and proactive documentation reviews.