UT Southwestern Medical Center-posted about 1 year ago
Full-time • Mid Level
Dallas, TX
Hospitals

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.

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