Specialist, Clinical Documentation Improvement at UTHealth in Houston, Texas

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.

Certification/Skills:

Must possess one or more of the following: Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P)
Must be willing to certify in CDI within 1 year of hire.

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
Outpatient Auditor experience is preferred
EPIC experience is preferred
Previous leadership or provider education experience is preferred

Minimum Education:

Associates degree is required.

Minimum Experience:

Minimum of five (5) years of experience in a combination of outpatient coding and clinical documentation improvement roles located in an outpatient or large provider office setting.

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