Clinical Documentation Integrity Quality Review RN

UT Southwestern Medical Center • Dallas, TX

394d

About The Position

The Clinical Documentation Integrity (CDI) Quality Review Nurse (QRN) at UT Southwestern is responsible for conducting second-level reviews of medical records to enhance the integrity of documentation. This role focuses on identifying risk variables and ensuring accurate representation of patient acuity and diagnosis-related groups (DRGs) in compliance with industry standards. The QRN will work closely with the CDI Manager and collaborate with coding teams to improve documentation processes and outcomes.

Requirements

• Bachelor's Degree in Nursing
• 5 years of patient care nursing experience in an acute care setting
• 3 years of Clinical Document Integrity experience
• Registered Nurse (RN) License upon hire
• CCDS or CDIP certification upon hire

Nice To Haves

• Master's Degree in Nursing
• 7 years of patient care nursing experience in an acute care setting
• 5 years of Clinical Document Integrity experience
• Experience working in a remote environment

Responsibilities

• Conduct post-discharge, pre-coding/billing reviews on targeted records for accurate capture of risk variables.
• Place physician queries for identified documentation opportunities and follow up for responses.
• Coordinate with the Coding Team to address coding opportunities as applicable.
• Utilize risk calculators and guidance documents to assess additional diagnoses impacting quality reporting.
• Maintain a summary of identified opportunities for feedback and education with the CDS Team and Providers.
• Identify and communicate process improvement opportunities for front-end corrections.
• Review criteria for second-level reviews and recommend updates to maximize quality impact.
• Maintain expert knowledge of CDI and coding guidelines.

Benefits

• Paid parental leave
• Paid holidays
• Health insurance
• Tuition reimbursement
• Paid time off
• Loan forgiveness
• Childcare assistance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Hospitals
• Education Level: Bachelor's degree