Clinical Documentation Improvement Specialist

Job Title & Specialty Area: Clinical Documentation Improvement Specialist

Department: Coding and CDI

Location: Dallas, TX

Shift: 8:00 AM to 5:30 PM

Job Type: Remote (Texas)

Why Children's Health?

At Children's Health, our mission is to Make Life Better for Children, and we recognize that their health plays a crucial role in achieving this goal.

Through our cutting-edge treatments and affiliation with UT Southwestern, we strive to deliver an extraordinary patient and family experience, ensuring that every moment, big or small, contributes to their overall well-being.

Our dedication to promoting children's health extends beyond our organization and encompasses the broader community. Together, we can make a significant difference in the lives of children and contribute to a brighter and healthier future for all.

Summary:

The Inpatient Clinical Documentation Integrity (CDI) Specialist promotes the accuracy, completeness, specificity, and integrity of clinical documentation through concurrent and retrospective medical record reviews. Collaborates with physicians, nursing staff, coding professionals, and interdisciplinary healthcare teams to ensure documentation accurately reflects the patient's clinical condition, severity of illness (SOI), risk of mortality (ROM), and complexity of care. Identifies opportunities for clarification of clinical documentation and facilitates compliant provider queries in accordance with established coding guidelines, regulatory requirements, and organizational policies. Supports accurate diagnosis reporting, DRG assignment, present-on-admission (POA) indicators, clinical validation, and quality reporting. Provides education to physicians and clinical staff while collaborating with coding, quality, and other departments to improve documentation practices, support accurate clinical data reporting, and promote optimal patient care outcomes.

Responsibilities:

• Interprets and implements requirements of APR-DRG and Medicare-based reimbursement/payers.
• Completes accurate and timely review to ensure the integrity of the documentation compliance resulting in accurate diagnosis and procedure classification used for reimbursement and quality metrics. Recognizes opportunities for documentation improvement using critical thinking skills. Uses critical thinking and sound judgment in decision making keeping reimbursement considerations in balance with regulatory compliance.
• Completes initial concurrent reviews of patient records for specified patient populations to evaluate documentation, to assign working DRG, pertinent secondary diagnoses and procedures for accurate APR-DRG assignment, risk of mortality and severity of illness.
• Strategically educates physicians and other clinicians regarding the need for accurate and complete documentation in the health record that includes regulations and compliance guidelines.
• Partners with coding professionals to ensure accuracy of diagnostic and procedure data and completeness of supporting documentation to determine appropriate APR-DRG assignment.
• Queries physicians regarding missing, unclear or conflicting health record documentation.

How You’ll Be Successful:

WORK EXPERIENCE

• At least 4 years Equivalent combination of education and/or experience in Health Information Management, Healthcare Administration, Healthcare Operations, Coding, Nursing, Case Management, or experience as a Physician. Required

• Four-year Bachelor's degree or equivalent experience Required
• Graduate or professional work or advanced degree; or equivalent experience Preferred

• Licensed medical doctor Preferred
• Licensed RN, RRT, PT Preferred
• Registered Health Information Management Technician / Administrator. Preferred
• CCS, CDIP, and or CCDS Preferred

A Place Where You Belong

We put our people first. We welcome, value, and respect the beliefs, identities and experiences of our patients and colleagues. We are committed to delivering culturally effective care, creating meaningful partnerships in the communities we serve, and equipping and developing our team members to make Children’s Health a place where everyone can contribute.

 Holistic Benefits – How We’ll Care for You:

· Employee portion of medical plan premiums are covered after 3 years.

· 4%-10% employee savings plan match based on tenure

· Paid Parental Leave (up to 12 weeks)

· Caregiver Leave

· Adoption and surrogacy reimbursement 

As an equal opportunity employer, Children's Health does not discriminate against employees or applicants because of race, color, religion, sex, gender identity and expression, sexual orientation, age, national origin, veteran or military status, disability, or genetic information or any other Federal or State legally-protected status or class. This applies to all aspects of the employer-employee relationship including but not limited to recruitment, hiring, promotion, transfer pay, training, discipline, workforce adjustments, termination, employee benefits, and any other employment-related activity.