Clinical Documentation Specialist (On-Site Only)

Job Summary

The Clinical Documentation Improvement (CDI) specialist is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This position will be responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of the patient's illness(es) as well as the level of services rendered. The CDI Specialist assesses clinical documentation through extensive review of the medical record, interaction with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate.

Qualifications

Education

• Required
  • Associate’s degree in nursing -or- Doctor of medicine
• Preferred
  • Bachelor's degree in nursing

Experience:

• Required
  • Five (5) years of experience in acute care/hospital setting and/or clinical coding
• Preferred
  • One (1) year of experience in clinical documentation improvement

Certification/Licensure:

• Required
  • Registered Nurse (RN) with Authorization to Practice in the State of Texas
    • Not required if a Medical Doctor
• Preferred
  • RHIT/RHIA/CDIP/CCDS or clinical documentation certification