University Of Texas Southwestern Medical Center

CLIN DOC INTGY SPEC

University Of Texas Southwestern Medical Center • $80K — $95K *
Dallas, TX 75217In-Person
Hospitals & Medical Centers
Less than 5 years of experience
Today
Be an Early Applicant
Job Overview by Ladders

Qualifications

  • 3 years of nursing experience in acute care hospitals, ideally in critical care settings.
  • 2 years of experience in a Clinical Documentation Integrity program, or 5 years overall in nursing with 3 in critical care.
  • Registered Nurse (RN) license required; CCDS or CDIP certification within 6 months post-hire is necessary.
  • Bachelor's Degree in Nursing (BSN) is preferred.
  • Experience in a remote working environment is valued.

Responsibilities

  • Review patient records to ensure accurate documentation of service levels and care acuity.
  • Communicate directly with physicians and multidisciplinary teams for complete and accurate documentation.
  • Initiate physician queries to clarify documentation following compliance guidelines.
  • Perform follow-ups on queries to ensure documentation clarity is maintained prior to discharge.
  • Collaborate with coding and quality teams to bridge documentation gaps between clinical content and coding language.
  • Maintain current knowledge of CDI practices and performance standards.
  • Provide support to other CDI Specialists as required.

Benefits

  • PPO medical plan available from day one at no cost for full-time employee-only coverage.
  • 100% coverage for preventive healthcare with no copay.
  • Paid Time Off available from day one.
  • Retirement programs through the Teacher Retirement System of Texas (TRS).
  • Paid parental leave benefit offered.
  • Wellness programs available for employees.
  • Tuition reimbursement to support further education.
  • Public Service Loan Forgiveness (PSLF) qualified employer status.
Full Job Description
JOB 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.

BENEFITS
UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include:
  • PPO medical plan, available day one at no cost for full-time employee-only coverage
  • 100% coverage for preventive healthcare-no copay
  • Paid Time Off, available day one
  • Retirement Programs through the Teacher Retirement System of Texas (TRS)
  • Paid Parental Leave Benefit
  • Wellness programs
  • Tuition Reimbursement
  • Public Service Loan Forgiveness (PSLF) Qualified Employer
  • Learn more about these and other UTSW employee benefits!


EXPERIENCE AND EDUCATION

Required
  • Experience
    3 years acute care Hospital nursing experience, preferably in critical care (i.e. ED, Trauma, Critical Care Units) and Two (2) years of experience working in a Clinical Documentation Integrity program or
    5 years nursing experience in an acute care Hospital including Three (3) years in critical care (i.e. ED, Trauma, Critical Care Units
  • Licenses and Certifications
    (RN) REGISTERED NURSE and
    (CCDS) Cert Clinical Documentation obtained upon hire or within 6 months after eligibility requirements are met or
    (CDIP) CERT DOCUMNTATN IMPROVMNT PRAC obtained upon hire or within 6 months after eligibility requirements are met
Preferred
  • Education
    Bachelor's Degree in nursing, BSN
  • Experience
    Experience working in a remote environment

JOB DUTIES
  • 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 (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.
  • Provide backup for other CDI Specialists as needed.
  • Support the Quality Standards set by UTSW and the HIM Coding & CDI Department.
  • Other duties as assigned.

About University Of Texas Southwestern Medical Center

The University of Texas Southwestern Medical Center (UT Southwestern) is a public academic health science center in Dallas, Texas. With approximately 14,400 employees and an operating budget of nearly $2.8 billion, UT Southwestern is one of six medical schools in the UT System. UT Southwestern is one of the leading medical research institutions in the world, with a focus on biomedical research, clinical care, and education. The institution is home to six Nobel laureates, 22 members of the National Academy of Sciences, and 19 members of the National Academy of Medicine. UT Southwestern is also affiliated with Parkland Memorial Hospital, one of the largest public hospitals in the United States.
Learn more about University Of Texas Southwestern Medical Center
Size
24,000 employees
Industry
Healthcare
* Ladders Estimates

Similar Jobs

Ad banner background

Get Ready For Your
Next Interview

More Jobs at University Of Texas Southwestern Medical Center

More Hospitals & Medical Centers Jobs

Find similar CLIN DOC INTGY SPEC jobs:

NationwideDallas, TX