Clinical Doc Improvement Spec. II

BJC HealthCare • St. Louis, MO

2h

About The Position

BJC HealthCare is seeking a Clinical Documentation Improvement Specialist II (CDIS II). The role uses clinical and coding knowledge to conduct clinically based concurrent and retrospective reviews of inpatient and outpatient medical records, evaluating clinical documentation and identifying opportunities to improve its quality. The specialist facilitates appropriate physician documentation of clinical conditions and procedures to support the patient's severity of illness, expected risk of mortality, and complexity of care.

The position contributes to content development and provider education, supports ongoing service-line documentation improvement initiatives, and participates in department and organization projects related to documentation improvement. It also analyzes CDI data and works with providers and leadership to identify documentation trends, issues, and potential solutions.

Requirements

• Nursing diploma or associate degree in nursing.
• 5–10 years of experience.
• Registered Nurse (RN) license.

Nice To Haves

• Bachelor's degree in nursing.

Responsibilities

• Engage providers and establish relationships that foster shared accountability for CDI and documentation improvement efforts.
• Identify trends, variances, deficiencies, and problems using aggregated data and information as part of the integrated clinical documentation improvement program.
• Perform provider- and group-level CDI data trend analysis, identify issues, and propose solutions to leadership.
• Contribute to service-line documentation improvement initiatives, including formal and informal provider education plans.
• Participate in department and organization projects related to documentation improvement.
• Contribute to the development of educational content based on analysis of clinical and financial information from internal and external sources.
• Interact and participate in formal and informal education for assigned service lines, including content creation, approval facilitation, meeting scheduling and frequency management, participation, and potentially content delivery.
• Conduct concurrent and retrospective reviews of inpatient and outpatient medical records to evaluate clinical documentation and identify improvement opportunities.
• Facilitate and obtain appropriate physician documentation of clinical conditions and procedures to support severity of illness, expected risk of mortality, and complexity of care.

Benefits

• Comprehensive medical, dental, vision, and life insurance, and legal services available on the first day of the month after hire.
• Disability insurance paid for by BJC.
• Annual 4% BJC Automatic Retirement Contribution.
• 401(k) plan with BJC match.
• Tuition assistance available on the first day.
• BJC Institute for Learning and Development.
• Health Care and Dependent Care Flexible Spending Accounts.
• Paid Time Off combining vacation, sick days, holidays, and personal time.
• Adoption assistance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree