Clinical Documentation Improvement Specialist III

Location: Dallas, Texas US

Notice

This position is no longer open.

Requisition Number: 19014776

Position Title:

External Description:

The Clinical Doc Improv Specialist III performs patient record reviews to determine complete, accurate and timely documentation of all conditions that support hospitalization and treatment of the patient. Present queries to physicians when needed to clarify ambiguous or incomplete documentation. Must have knowledge of ICD-10, Complications/Comorbid Conditions and their role in the final Diagnosis Related Group, Severity of Illness, and Risk of Mortality. The essential functions of the Clinical Doc Improv Specialist III include the following:
  • Facilitates accurate, timely, and complete documentation of medical conditions and treatment in patient records.
  • Performs review of record to determine complete, accurate documentation of patient condition and treatment. When appropriate, update working DRG.
  • Demonstrates ability to recommend proficient query\ies to practitioners or support staff regarding missing, unclear, or conflicting health record documentation in an effort to obtain additional documentation within the health record as needed. Appropriately escalates provider non-responses or inappropriate responses for reconciliation.
  • Collaborates with Health Information Management coders, other Clinical Documentation Improvement Specialists and others to reconcile potential documentation and coding opportunities.  This might include analyzing working versus final coded DRG.
  • Collaboratively works with interdisciplinary teams including, but not limited to physicians, mid-level providers, nurses, Patient Safety staff and Health Information Improvement teams.
  • Develops and/or provides ongoing education and information regarding documentation opportunities to practitioners, Health Information Management Coders, and other Clinical Documentation Improvement Specialists.  Promotes related education to others such as allied health professionals, Administration, Utilization Review, Comprehensive Care specific to documentation and its effect on SOI, ROM, CMI, reimbursement and data reporting.
  • Formulates, interprets, and analyzes data relative to opportunities to improve documentation practices. Prepares CDI metric based documents for senior leadership and medical staff groups/divisions.
  • Serves on internal Hospital committees relating to CDI, CMI and ELOS along with functioning as a subject matter expert and problem solver.
The ideal Clinical Doc Improv Specialist III candidate will have strong oral and written communication skills, clinical knowledge of disease process, and knowledge of medical necessity rules.
  • Location/Facility � Baylor Scott & White Health
    For more information on the facility, please click our Locations link.
  • Specialty/Department/Practice � HIM
  • Shift/Schedule � Full-Time, Days
  • Benefits � Our competitive benefits package includes*:
    • Immediate eligibility for health and welfare benefits
    • 401(k) savings plan with dollar-for-dollar match up to 5%
    • Tuition Reimbursement
    • PTO accrual beginning Day 1
*Note: Benefits may vary based upon position type and/or level.
 


  • Master�s degree required
  • 5+ years of related work experience required
  • Certified Coding Specialist (CCS) certification required
  • Certified Cardiac Device Specialist (CCDS) certification required

City:

State:

Community / Marketing Title: Clinical Documentation Improvement Specialist III

Company Profile:

Location_formattedLocationLong: Dallas, Texas US

CountryEEOText_Description: We are an equal opportunity employer committed to ensuring a diverse workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law. To view the most recent EEO is the Law Poster, click here.

As a health care system committed to improving the health of those we serve, we are asking our employees to model the same behaviors that we promote to our patients. As of January 1, 2012, Baylor Scott & White Health no longer hires individuals who use nicotine products.

We are an equal opportunity employer committed to ensuring a diverse workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law. To view the most recent EEO is the Law Poster, click here.