HIM CDI Specialist I

Parkland Health

2d • Onsite

About The Position

The Clinical Documentation Integrity Specialist (CDIS) performs patient record reviews to establish complete, accurate and timely documentation of all conditions that support hospitalization and treatment of the patient. Present queries to the medical staff when needed to clarify ambiguous or incomplete documentation. Must have knowledge of ICD-10, Complications/Comorbid Conditions and their role in the final Diagnosis Related Group, Severity of Illness and Risk of Mortality.

Requirements

• For MD or DO: Must have two (2) years of clinical experience
• For RNs: Three plus (3+) years of clinical experience in an acute care setting (ICU/Critical Care / Surgery Specialty)
• For HIM Professionals: Must have two plus (2+) years of experience working with the coding classification systems, medical terminology, anatomy and physiology and disease processes.
• Two (2) years of inpatient coding experience
• Must have current RN license or valid temporary permit with the Texas Board of Nursing; or, valid Compact RN license.
• Must have current Certified Coding Specialists (CCS), or Registered Health Information Technology (RHIT), or Registered Health Information Management Administrator (RHIA).
• Organizational, analytical, writing and interpersonal skills.
• Must be able to be comfortable teaching in group settings as a large part of the job is educating healthcare providers about current documentation standards and helping them appreciate their role in documentation improvement.
• Must possess expert knowledge of medical terminology, anatomy & physiology and ICD-10 and CPT coding principles.
• Must be able to communicate effectively with physicians, nursing and ancillary staff.
• Must be able to demonstrate patient centered/patient valued behaviors.
• Must demonstrate knowledge and skill in age specific needs and the elements of disease processes and related procedures.
• Must be able to demonstrate a working knowledge of MS Office software, including Word, Excel, and PowerPoint.
• RN applicants must maintain standards of professional conduct and performs all assigned and unassigned duties in accordance with the current State of Texas Nurse Practice Act.
• RN Applicants must pass Medication Examination prior to hospital orientation.
• Current Parkland employees requesting reassignment to role must have current Medication Examination on file.

Nice To Haves

• Degree in nursing from an accredited college or university.
• A medical degree (MD, DO) Master’s Degree in a Healthcare/Medical related field from an U.S. accredited college or university
• Graduated from an accredited Health Information Management (HIM) program.
• Equivalent Education and/or Experience May have an equivalent combination of education and experience in lieu of specified educational and experience requirements.

Responsibilities

• Collaborates with physician, physician extender, nurse, case manager/utilization reviewer and HIM coder to identify principal diagnosis options, secondary diagnoses and procedures, to assign working MS-DRGs and or APR-DRG for at least 85% of identified populations.
• Conducts initial and extended-stay concurrent reviews on all selected admissions and documents findings within 3M CDIS software.
• Identifies need to clarify documentation in records and utilizes strong communication skills with physician, physician extender, nurse or other healthcare professionals, utilizing appropriate tools to capture needed documentation.
• Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient's severity of illness and risk of mortality.
• Serves as a resource to physicians and administration regarding issues to the appropriateness of inpatient MS-DRG and APR-DRG assignment.
• Assists in the development of query response physician reports.
• Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.
• Provides information and in-services as necessary to physician and ancillary staff.
• Identifies ways to improve work processes and improve customer satisfaction.
• Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of the department and Parkland.
• Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure.
• Integrates knowledge gained into current work practices.
• Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area.
• Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans.
• Seeks advice and guidance as needed to ensure proper understanding.

Benefits

• A career at Parkland means joining a collaborative, engaged team focused on excellence, innovation, and patient-centered service.
• Our employees are supported with resources to grow, succeed, and make a meaningful impact every day.

What This Job Offers

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