Your future role at a glanceLocation: Partially Remote- Will support sites within Austin, TX & Waco, TX
Department/Specialty: Clinical Documentation Integrity
Schedule: Full Time | Days | Monday-Friday
Salary: $96,208.99-$134,109.89
#LI-AM2
How you'll make an impact in this role- Assess the accuracy, consistency, and compliance of clinical documentation reviews performed by front-line CDS. Supports the professional development of the CDI team and provides provider-facing education to improve clinical documentation practices.
- Perform routine and ad hoc audits of CDI queries, documentation reviews, and EHR entries for compliance with internal standards, industry guidelines, and regulatory requirements.
- Evaluate query appropriateness, clinical evidence, and alignment with coding rules (ICD-10-CM/PCS, UHDDS, CMS).
- Identify trends, variances, and opportunities for improvement in CDI team performance. Maintain internal audit tools, track performance metrics, and present findings to leadership on a regular basis
- Provide one-on-one coaching for new or developing team members, based on audit findings or performance trends. Create and maintain educational materials, tip sheets, and query templates in accordance with evolving CDI best practices.
What minimum requirements you'll needLicensure / Certification / Registration:
Required Credential(s):
- Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
Education:
- High School diploma equivalency with 2 years of cumulative experience OR Associate'
degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.
What additional preferences we're seeking- Must have a Certified Clinical Documentation Specialist (CCDS)certification from the Association of Clinical Documentation Improvement Specialists (ACDIS)
- Expert understanding of CDI best practices, DRG methodologies (MS-DRG and APR-DRG), and coding principles.
- Strong knowledge of SOI/ROM, MCC/CC capture, risk adjustment, quality indicators (PSI, HAC, mortality), and CMS compliance.
- Proficiency with audit tools, EHR systems (e.g., Epic), and CDI software platforms (e.g., Iodine, 3M, Nuance).
Responsibilities- Assess the accuracy, consistency, and compliance of clinical documentation reviews performed by front-line CDS. Supports the professional development of the CDI team and provides provider-facing education to improve clinical documentation practices.
- Perform routine and ad hoc audits of CDI queries, documentation reviews, and EHR entries for compliance with internal standards, industry guidelines, and regulatory requirements.
- Evaluate query appropriateness, clinical evidence, and alignment with coding rules (ICD-10-CM/PCS, UHDDS, CMS).
- Identify trends, variances, and opportunities for improvement in CDI team performance. Maintain internal audit tools, track performance metrics, and present findings to leadership on a regular basis
- Provide one-on-one coaching for new or developing team members, based on audit findings or performance trends. Create and maintain educational materials, tip sheets, and query templates in accordance with evolving CDI best practices.
- Develop and deliver comprehensive CDI education programs, including onboarding, continuing education, and skills refreshers.
QualificationsLicensure / Certification / Registration:
Required Credential(s):
- Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
Education:
- High School diploma equivalency with 2 years of cumulative experience OR Associate'
degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.
