Clinical Document Integrity Specialist

Why UT Southwestern?

With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the #1 hospital in Dallas-Fort Worth for the fifth consecutive year, we invite you to continue your healthcare career with us at William P. Clements Jr. University Hospital. You’ll discover a culture of teamwork, professionalism, and consistent opportunities for learning and advancement into leadership roles. All full-time employees will have a robust benefits package including employer paid medical insurance. Children and family medical insurance plans are available at a cost to the employee. 

To learn more about the benefits UT Southwestern offers visit https://www.utsouthwestern.edu/employees/hr-resources/.

Job Duties 

• Facilitates appropriate clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record to improve overall quality and completeness of clinical documentation. 
• Communicates effectively (face-to-face) with Physicians, the Healthcare Team, and Multidisciplinary Teams to ensure accurate and complete documentation of all relevant diagnoses, procedures and treatments.
• Provides education on clinical documentation opportunities to support acuity, quality, and coding. 
• Initiates Physician Queries for clarification and specificity as appropriate, following established query guidelines for compliant queries.
• Performs follow-ups to ensure clarification was documented prior to discharge. 
• Performs follow-up reviews and updates CDI/DRG worksheet to reflect changes in patient status, to verify the most appropriate Prin Dx and DRG and validate supporting documentation. 
• Works collaboratively with the Coding and Quality Teams to ensure the clinical documentation fills the gaps between clinical and coding language. 
• Maintains an expert level of knowledge of CDI related practice and performance. 
• Other Duties: Performs other duties as assigned.

Experience and Education

• 3 years nursing experience in an acute care Hospital setting, preferred in critical care; and 3 years experience working in a Clinical Documentation Integrity program;
• 5 years nursing experience in an acute care Hospital in critical care (i.e. ED, Trauma, Critical Care Units) in lieu of 3 years of CDI experience.RN required, BSN preferred RN required; and with a (CCDS) Certified Clinical Documentation Specialist certification, or (CDIP) Certified Documentation Improvement Practitioner certification, or must attain CCDS or CDIP within 6 months in the position; for those without CDI experience must attain CCDS credential after completing the required (2) years in CDI to sit for the exam.
• Also, prefer (CCS) Certified Coding Specialist.

Security

This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. In accordance with federal and state law, the University prohibits unlawful discrimination, including harassment, on the basis of: race; color; religion; national origin; sex; including sexual harassment; age; disability; genetic information; citizenship status; and protected veteran status. In addition, it is UT Southwestern policy to prohibit discrimination on the basis of sexual orientation, gender identity, or gender expression.