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 sixth 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

UT Southwestern is honored to be a Veteran Friendly work environment that is home to approximately 800 veterans.  We value your integrity, dedication, and the commitment you’ve made to our country.  We’re proud to support your next mission.

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

 Summary

The CDI Specialist facilitates appropriate clinical documentation reviews concurrently 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 with Physicians and the Healthcare Team.  Initiates Provider queries as appropriate for documentation clarification and specificity.

Experience and Education

• RN required, BSN preferred
• Required – Three (3) years acute care Hospital nursing experience, preferred in critical care (i.e. ED, Trauma, Critical Care Units) and Two (2) years of experience working in a Clinical Documentation Integrity program; an equivalent combination of education and experience may be considered
• Or, Five (5) years’ nursing experience in an acute care Hospital including Three (3) years in critical care (i.e. ED, Trauma, Critical Care Units), in lieu of Two (2) years of CDI experience
• Required – Certification: (CCDS) Certified Clinical Documentation Specialist, or (CDIP) Certified Documentation Improvement Practitioner; or must attain CCDS or CDIP within 6 months after eligibility requirements are met
• Must be proficient with computers, working knowledge of 3M 360 & Epic preferred; or similar electronic systems
• Experience working in a remote environment preferred

Essential Functions

• Reviews patient records concurrently 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 with Physicians, Healthcare Team, and Multidisciplinary Teams
• Provis education on clinical documentation opportunities to support acuity, quality, and coding
• Initiates Provider queries for clarification and specificity to ensure complete documentation for all relevant diagnoses, procedure, and treatments, following established query guidelines for compliant
• queries
• Performs follow-ups on queries, per process, to ensure clarification was documented prior to discharge
• Performs timely follow-up reviews and updates the CDI/DRG worksheet to reflect changes in patient status, verify the most appropriate PDx and DRG, and validate supporting documentation
• Provide backup for other CDI Specialists as needed
• Works collaboratively with Coding and Quality Teams to ensure the clinical documentation fills the ‘gaps’ ween clinical and coding language
• Support the Quality Standards set by UTSW and the HIM Coding & CDI Department
• Maintains an expert level of knowledge of CDI related guidelines and practices

Other duties as assigned

Knowledge, Skills, and Abilities

• Work requires organizational skills along with a high level of accuracy and attention to detail
• Work requires the ability to set priorities and reprioritize as needed to meet performance goals, etc.
• Work requires excellent customer service, interpersonal, and communication skills (verbal and written)
• Work requires ability to handle multiple tasks, show initiative, and quickly adapt to changes as necessary
• Work requires strong analytical and critical thinking skills
• Work requires ability to report and problem solve using discretion, judgment, and professionalism
• Work requires ability to perform in a conservative, fast-paced, and quality driven environment
• Work requires ability to comprehend, understand, and follow established policies, procedures, and other guidelines of some complexity

Work requires self-motivation, maturity, and being a team player

Working Conditions

This job is Majority Remote, however could include some minimal on-site participation for annual Consultant educational visits, and occasional internal provider CDI educational presentations

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. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status. To learn more, please visit: https://jobs.utsouthwestern.edu/why-work-here/diversity-inclusion