Specialist, Clinical Documentation Improvement at UTHealth in Houston, Texas

Posted in General Business 14 days ago.

Type: Full-Time

Job Description:

Position Summary:

The Clinical Documentation Improvement Specialist (CDIS), working under the direction of the Manager, CDI, utilizes compliant documentation improvement principles and coding expertise to identify areas of opportunity that impact the quality and the completeness of the medical record documentation. Through current, prospective, and retrospective evaluation of the medical record documentation, the CDIS will be responsible for working collaboratively with the billing providers to clarify documentation, support medical necessity, and provide education with the end goal of achieving improved documentation results and reduction of unnecessary denials for the organization. The CDIS will determine and initiate CDI program services.

Position Key Accountabilities:

1. Identifies service areas or individual providers that would benefit from the CDI program based on CDI audits.
2. Works collaboratively with the coding team and billing compliance to determine needed CDI resources in identified risk areas.
3. Effectively communicates, educates and audits patient records for program effectiveness.
4. Responsible for ensuring provider CDI query compliance and providing feedback to the medical staff and applicable department leadership participating in the CDI program.
5. Provides CDI program education to billing provider and coders.
6. Tracks and provides metric data for program effectiveness to CDI Manager.
7. Performs other duties as assigned.


One of the following coding certifications is required:
Certified Coding Specialist (CCS) or Certified Coding Specialist-Physician-based (CCS-P).
And one of the following documentation certifications is also required:
Certified Documentation Improvement Practitioner (CDIP) certification or Certified Clinical Documentation Specialist (CCDS) certification. Analytical skills, ability to interpret data, and generate reports, overall turning valuable data into presentable information for providers. Proficiency in Microsoft Office suite. The ability to abstract data and maintain a database.

Minimum Education:

Associates degree in a Healthcare related field.

Minimum Experience:

Three years of experience in a combination of outpatient coding and clinical documentation improvement roles located in an outpatient or large provider office setting. Previous leadership or provider education experience. May substitute required experience with equivalent years of education beyond the minimum education requirement.

Physical Requirements:

Exerts up to 20 pounds of force occasionally and/or up to 10 pounds frequently and/or a negligible amount constantly to move objects.

Security Sensitive:

This job class may contain positions that are security sensitive and thereby subject to the provisions of Texas Education Code § 51.215