Clinical Documentation Improvement Specialist 1, 100% Remote, Anywhere

Remote, United States Category Shared Services Job Type Full Time Day Job Job Id 25012577 About Us Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well. Our Core Values are: • We serve faithfully by doing what's right with a joyful heart. • We never settle by constantly striving for better. • We are in it together by supporting one another and those we serve. • We make an impact by taking initiative and delivering exceptional experience. Benefits Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include: • Eligibility on day 1 for all benefits • Dollar-for-dollar 401(k) match, up to 5% • Debt-free tuition assistance, offering access to many no-cost and low-cost degrees, certificates and more • Immediate access to time off benefits At Baylor Scott & White Health, your well-being is our top priority. Note: Benefits may vary based on position type and/or level Job Summary 100% Remote position Clinical Documentation Improvement Specialist 1 reviews patient records to ensure complete and accurate documentation. They create queries for physicians to clarify unclear documentation. The specialist should know ICD-10, Complications/Comorbid Conditions, and their role in Diagnosis Related Group, Severity of Illness, and Risk of Mortality. The pay range for this position is $37.35/hour (entry level qualifications) - $57.89/hour (highly experienced). The specific rate will depend upon the successful candidate's specific qualifications and prior experience. Essential Functions of the Role • Facilitates accurate and complete documentation of medical conditions and treatment in patient records. • Performs review of records to ensure complete, accurate documentation of patient condition and treatment. Updates the working DRG as appropriate. • Promotes and obtains documentation for clinical conditions or procedures. This supports the severity of illness, risk of mortality, and complexity of care through interaction with practitioners. • Query practitioners about missing, unclear, or conflicting health record documentation to obtain additional information as needed. • Appropriately escalates provider non-responses or inappropriate responses for reconciliation. • Collaborates with Health Information Management coders and or auditors to reconcile working versus final coded DRG. • Collaborates with peers who work directly with physicians. Key Success Factors • Must have an Associate's degree in nursing or Health Information Management or Health Informatics. • Must be a Registered Nurse (RN) or Registered Health Information Technologist (RHIT) • May require one of these certifications: Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS), BSW code (CCDOSCP), Certified Clinical Documentation Specialist Outpatient (CCDS-O), Certified Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC). • 4 years of nursing Acute Care, Quality, or Case Management or 4 years of inpatient coding. • Knowledge of ICD-10, Complications/Comorbid Conditions, and how each establishes the final Diagnosis Related Group, Severity of Illness, and Risk of Mortality. • Able to establish complete, accurate and timely documentation of all conditions. • Able to obtain missing, ambiguous or incomplete information from practitioners. • Able to examine and interpret data in order to improve documentation practices. • Able to collaboratively work with interdisciplinary teams. • Able to provide ongoing education and information to practitioners regarding documentation practices. Belonging Statement We believe that all people should feel welcomed, valued and supported, and that our workforce should be reflective of the communities we serve. QUALIFICATIONS • EDUCATION - Associate's • MAJOR - Nursing • EXPERIENCE - 4 Years of Experience • CERTIFICATION/LICENSE/REGISTRATION - Reg Health Information Technic (RHIT), Registered Nurse (RN): Registered Nurse (RN) or Registered Health Information Technologist (RHIT). Apply tot his job Apply tot his job