Coding and CDI

3 weeks ago

Dallas, United States Children's Health Full time

Job Title & Specialty Area: Clinical Documentation Improvement Specialist

Department: Coding and CDI

Location: Dallas | Trinity Towers

Shift: Monday - Friday 8am -4:30pm

Job Type: Remote

Why Children’s Health?
At Children's Health, our mission is to Make Life Better for Children, and we recognize that their health plays a crucial role in achieving this goal.

Through our cutting-edge treatments and affiliation with UT Southwestern, we strive to deliver an extraordinary patient and family experience, ensuring that every moment, big or small, contributes to their overall well-being.

Our dedication to promoting children's health extends beyond our organization and encompasses the broader community. Together, we can make a significant difference in the lives of children and contribute to a brighter and healthier future for all.

Summary:
The clinical documentation integrity specialist collaborates extensively with physicians, nursing staff, other patient clinical and coding staff to improve the quality and completeness of documentation of care provided and coded for coordination, abstraction, and submission of accurate data. CDI Specialist will review medical records for opportunities for diagnosis clarification and validity as it pertains to DRG assignment, severity of illness, risk of mortality, and case mix data as well as timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Communicates with and assist with educating all physician and clinical staff related to accurate and complete clinical documentation. 

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.

How You’ll Be Successful:

WORK EXPERIENCE

* At least 4 years Equivalent combination of education and/or experience in Health Information Management, Healthcare Administration, Healthcare Operations, Coding, Nursing, Case Management, or experience as a Physician
* Req

EDUCATION
* Four-year bachelor's degree or equivalent experience Req
* Graduate or professional work or advanced degree; or equivalent experience Pref

LICENSES AND CERTIFICATIONS
* Licensed medical doctor Pref
* Licensed RN, RRT, PT Pref
* Registered Health Information Management Technician / Administrator Pref

A Place Where You Belong

We put our people first. We welcome, value, and respect the beliefs, identities and experiences of our patients and colleagues. We are committed to delivering culturally effective care, creating meaningful partnerships in the communities we serve, and equipping and developing our team members to make Children’s Health a place where everyone can contribute.

 Holistic Benefits – How We’ll Care for You:

· Employee portion of medical plan premiums are covered after 3 years.

· 4%-10% employee savings plan match based on tenure

· Paid Parental Leave (up to 12 weeks)

· Caregiver Leave

· Adoption and surrogacy reimbursement >

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