Job Number: 105706
Location: 5323 Harry Hines Blvd, Dallas, TX
Department: 844002 - HIM Coding and CDI
Full/Part Time/PRN: Day Job
This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information
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.
1. 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.
2. 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.
3. 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.
4. 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.
5. Works collaboratively with the Coding and Quality Teams to ensure the clinical documentation fills the 'gaps' between clinical and coding language.
6. Maintains an expert level of knowledge of CDI related practice and performance.
**Other Duties: Performs other duties as assigned.
UTSouthwestern 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 UTSouthwestern policy to prohibit discrimination on the basis of sexual orientation, gender identity, or gender expression.