Clinical Document Improvement Specialist

Clincial Document Improvement Specialist

Dallas, Texas | Health Information Management

Job Summary
The clinical documentation specialist collaborates extensively with physicians, nursing staff, other patient caregivers and coding staff to improve the quality and completeness of documentation of care provided and coded for coordination, abstraction, and submission of accurate data required by CMS. Facilitates concurrent modifications to clinical documentation to ensure commensurate reimbursement of clinical severity and services rendered to patients with a Diagnosis Related Group based payer (Medicare, Medicaid). Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Communicates with and educates all physician and clinical staff concerning accurate and effective clinical documentation.

This is a full-time, and fully remote position.

Responsibilities:
Interprets and implements requirements of APR-DRG and Medicare-based reimbursement/payers.
Completes accurate and timely review to ensure the integrity of the documentation compliance resulting in accurate diagnosis and procedure classification used for reimbursement and quality metrics. Recognizes opportunities for documentation improvement using critical thinking skills.
Uses critical thinking and sound judgment in decision making keeping reimbursement considerations in balance with regulatory compliance.
Completes initial concurrent reviews of patient records for specified patient populations to evaluate documentation, to assign working DRG, pertinent secondary diagnoses and procedures for accurate APR-DRG assignment, risk of mortality and severity of illness.
Strategically educates physicians and other clinicians regarding the need for accurate and complete documentation in the health record that includes regulations and compliance guidelines.
Partners with coding professionals to ensure accuracy of diagnostic and procedure data and completeness of supporting documentation to determine appropriate APR-DRG assignment.
Queries physicians regarding missing, unclear or conflicting health record documentation.

WORK EXPERIENCE

At least 4 years Equivalent combination of education and/or experience in Health Information Management, Healthcare Administration, Healthcare Operations, Coding, Nursing, Case Managementor experience as a Physician. Required.
Clinical documentation improvement/integrity.
3-5 years of inpatient coding experience in an acute care facility-Preferred
EDUCATION

Four-year Bachelor's degree or equivalent experience-Required
Graduate or professional work or advanced degree; or equivalent experience-Preferred
LICENSES AND CERTIFICATIONS

Licensed medical doctor-Preferred
Licensed RN,RRT,PT-Preferred
Registered HIM Technician/Administrator-Preferred

About Us

Children’s Health values the role each member of our team plays in helping us make life better for children. We employ more than 7,500 people and provide rewarding career opportunities that help them reach their highest potential. We also hold Magnet recognition from the American Nurses Credentialing Center for nursing excellence, we serve as the primary pediatric teaching facility for the University of Texas Southwestern Medical Center , and we are widely recognized for delivering high quality care . Children’s Health has also been named one of the 150 Top Places to Work in Healthcare by Becker’s Healthcare for nine consecutive years.

Benefits
Children’s Health offers competitive pay, a comprehensive benefits program and opportunities for learning and career development. We promote a diverse and inclusive workplace, and our team members have a voice in their work through surveys and town halls. We invite you to learn more about Children’s Health.