WHY UT SOUTHWESTERN?

With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the number 1 hospital in Dallas-Fort Worth according to U.S. News & World Report , we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you’ll discover a culture of teamwork, professionalism, and a rewarding career!

JOB SUMMARY

The CDI Specialist facilitates appropriate clinical documentation reviews concurrently to ensure that the level of services and acuity of care are accurately reflected in the medical record to improve overall quality and completeness of clinical documentation. Communicates effectively with Physicians and the Healthcare Team. Initiates Provider queries as appropriate for documentation clarification and specificity.

EXPERIENCE AND EDUCATION

Required
Experience
3 years acute care Hospital nursing experience, preferably in critical care (i.e. ED, Trauma, Critical Care Units) and Two (2) years of experience working in a Clinical Documentation Integrity program or
5 years nursing experience in an acute care Hospital including Three (3) years in critical care (i.e. ED, Trauma, Critical Care Units
Licenses and Certifications
(RN) REGISTERED NURSE and
(CCDS) Cert Clinical Documentation obtained upon hire or within 6 months after eligibility requirements are met or
(CDIP) CERT DOCUMNTATN IMPROVMNT PRAC obtained upon hire or within 6 months after eligibility requirements are met
Preferred
Education
Bachelor’s Degree in nursing, BSN
Experience
Experience working in a remote environment

Reviews patient records concurrently to ensure that the level of services and acuity of care are accurately reflected in the medical record to improve overall quality and completeness of clinical documentation.
Communicates effectively (face-to-face) with Physicians, the Healthcare Team, and Multidisciplinary Teams to ensure accurate and complete documentation of all relevant diagnoses, procedures and treatments. Provides education on clinical documentation opportunities to support acuity, quality, and coding.
Initiates Physician Queries for clarification and specificity as appropriate, following established query guidelines for compliant queries. Performs follow-ups to ensure clarification was documented prior to discharge.
Performs follow-up reviews and updates CDI/DRG worksheet to reflect changes in patient status, to verify the most appropriate Prin Dx and DRG and validate supporting documentation.
Works collaboratively with the Coding and Quality Teams to ensure the clinical documentation fills the ‘gaps’ between clinical and coding language.
Maintains an expert level of knowledge of CDI related practice and performance.
Provide backup for other CDI Specialists as needed.
Support the Quality Standards set by UTSW and the HIM Coding & CDI Department.
Other duties as assigned.