Qualifications

• 3 years of acute care hospital nursing experience, preferably in critical care (ED, Trauma, Critical Care Units) and 2 years in a Clinical Documentation Integrity program, or 5 years of nursing experience with 3 years in critical care.
• Registered Nurse (RN) license required.
• Clinical Documentation Specialist certification (CCDS) or Clinical Documentation Improvement Practitioner (CDIP) certification required within 6 months of hiring.
• Bachelor's Degree in Nursing (BSN) preferred.
• Experience working remotely is a plus.

Responsibilities

• Review patient records to ensure accurate clinical documentation reflective of service levels and care acuity.
• Communicate face-to-face with physicians and multidisciplinary teams to guarantee comprehensive documentation of diagnoses and treatments.
• Initiate and follow up on physician queries to clarify documentation as per established guidelines.
• Update CDI/DRG worksheets based on patient status changes and validate supporting documentation.
• Collaborate with Coding and Quality Teams to bridge gaps in clinical documentation and coding language.
• Maintain expert knowledge of CDI practices and performance standards.
• Provide backup support to other CDI Specialists as needed.

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 required.
• Paid Time Off available from day one.
• Retirement Programs through the Teacher Retirement System of Texas (TRS).
• Paid Parental Leave Benefit.
• Wellness programs available for employees.
• Tuition Reimbursement offered.
• Position qualifies for Public Service Loan Forgiveness (PSLF).