UT Health Specialist, Clinical Documentation Improvement in Texas Medical Center-Houston, Texas
Specialist, Clinical Documentation Improvement
Texas Medical Center-Houston, Texas
McGovern Medical School at UTHealth
Requisition #: 210000CT
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:
Identifies service areas or individual providers that would benefit from the CDI program based on CDI audits.
Works collaboratively with the coding team and billing compliance to determine needed CDI resources in identified risk areas.
Effectively communicates, educates and audits patient records for program effectiveness.
Responsible for ensuring provider CDI query compliance and providing feedback to the medical staff and applicable department leadership participating in the CDI program.
Provides CDI program education to billing provider and coders.
Tracks and provides metric data for program effectiveness to CDI Manager.
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.
Associates degree in a Healthcare related field.
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.
Exerts up to 20 pounds of force occasionally and/or up to 10 pounds frequently and/or a negligible amount constantly to move objects.
This job class may contain positions that are security sensitive and thereby subject to the provisions of Texas Education Code § 51.215
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University of Texas Health Science Center at Houston (UTHealth)
Established in 1972 by The University of Texas System Board of Regents, The University of Texas Health Science Center at Houston (UTHealth) is Houston’s Health University and Texas’ resource for health care education, innovation, scientific discovery and excellence in patient care. The most comprehensive academic health center in the UT System and the U.S. Gulf Coast region, UTHealth is home to schools of biomedical informatics, biomedical sciences, dentistry, nursing and public health and the John P. and Kathrine G. McGovern Medical School. UTHealth includes The University of Texas Harris County Psychiatric Center, as well as the growing clinical practices UT Physicians, UT Dentists and UT Health Services. The university’s primary teaching hospitals are Memorial Hermann-Texas Medical Center, Children’s Memorial Hermann Hospital and Harris Health Lyndon B. Johnson Hospital.
UTHealth offers a comprehensive and competitive benefits package. For more information on our benefits programs please refer to the UTHealth Office of Benefits Website.
Equal Employment Opportunity Statement
UTHealth is committed to providing equal opportunity in all employment-related activities without regard to race, color, religion, sex, sexual orientation, national origin, age, disability, genetic information, gender identity or expression, veteran status or any other basis prohibited by law or university policy. Reasonable accommodation, based on disability or religious observances, will be considered in accordance with applicable law and UTHealth policy. The University maintains affirmative action programs with respect to women, minorities, individuals with disabilities, and eligible veterans in accordance with applicable law.