HIM CDI Specialist I

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

Primary Purpose:

The Clinical Documentation Integrity Specialist (CDIS) applies clinical knowledge to analyze and to interpret health records. Proficiently applies ICD-10 coding to in-house patients. Analyzes records for optimization of physician documentation and query potential if required. Provides education to providers, coders, case management and interacts with other departments as required. Tracks pre and post DRG data. Performs varied, difficult and specialized tasks without detailed guidance, is expected to exercise judgment and apply expert knowledge.

Minimum Specifications Education:

Must have a degree in nursing from an accredited college or university OR a medical degree

Master's Degree in a Healthcare/Medical related field from an U.S. accredited college or university OR

Graduated from an accredited Health Information Management program

Experience:

For RNs:

Three plus (3+) years of clinical experience in an acute care setting (ICU/Critical Care / Surgery Specialty)

For HIM Professionals:

Must have two plus (2+) years of experience working with the coding classification systems, medical terminology, anatomy and physiology and disease processes OR

Two (2) years of inpatient coding experience

Equivalent Education and/or Experience:

May have an equivalent combination of education and experience to substitute for both the education and the experience requirements.

Certification/Registration/Licensure:

Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) certification is preferred

For MDs:

Must have graduated from a medical school and obtained a Medical Degre

For RNs:

Must have current RN license or valid temporary permit with the Texas Board of Nursing; or, valid Compact RN license.

For HIM Professionals Only: Must have current Certified Coding Specialists (CCS), or

Registered Health Information Technology (RHIT), or

Registered Health Information Management Administrator (RHIA).

Skills or Special Abilities:

Organizational, analytical, writing and interpersonal skills.

Must be able to be comfortable teaching in group settings as a large part of the job is educating healthcare providers about current documentation standards and helping them appreciate their role in documentation improvement.

Must possess expert knowledge of medical terminology, anatomy & physiology and ICD-10 and CPT coding principles.

Must be able to communicate effectively with physicians, nursing and ancillary staff.

Must be able to demonstrate patient centered/patient valued behaviors.

Must demonstrate knowledge and skill in age specific needs and the elements of disease processes and related procedures.

Prefer applicant has knowledge of ICD-10-CM and ICD-10-CM/PCS coding conventions and/or clinical auditing processes.

Must be able to demonstrate a working knowledge of MS Office software, including Word, Excel, and PowerPoint.

For RN applicants:

RN applicants must maintain standards of professional conduct and performs all assigned and unassigned duties in accordance with the current State of Texas Nurse Practice Act.

RN Applicants must pass Medication Examination prior to hospital orientation.

Current Parkland employees requesting reassignment to role must have current Medication Examination on file

Responsibilities:

1. Collaborates with physician, physician extender, nurse, case manager/utilization reviewer and HIM coder to identify principal diagnosis options, secondary diagnoses and procedures, to assign working MS-DRGs and or APR-DRG for at least 85% of identified populations.

2. Conducts initial and extended-stay concurrent reviews on all selected admissions and documents findings within 3M CDIS software.

3. Identifies need to clarify documentation in records and utilizes strong communication skills with physician, physician extender, nurse or other healthcare professionals, utilizing appropriate tools to capture needed documentation. Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient's severity of illness and risk of mortality.

4. Serves as a resource to physicians and administration regarding issues to the appropriateness of inpatient MS-DRG and APR-DRG assignment.

5. Assists in the development of query response physician reports. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data. 6. Provides information and in-services as necessary to physician and ancillary staff.

Job Accountabilities:

Identifies ways to improve work processes and improve customer satisfaction.

Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of the department and Parkland.

Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.

Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area.

Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.