The Clinical Documentation Improvement (CDI) specialist is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This position will be responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient, improve patient quality, acuity and risk of mortality, as well as the level of services rendered. The CDI Specialist assesses clinical documentation through extensive review of the medical record, interaction with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate.
Experience & Education:
Associate’s degree in nursing, Heath Information Management or healthcare related field required.
Texas Licensed healthcare professional. Current RN, required.
For the RHIA or RHIT with CCS certification required
RN or RHIA, RHIT and/or CCS required.
A minimum of 5 years clinical experience in acute care specialty area (ICU, ED, NICU and telemetry/cardiac) required. And 2 years of CDI or DRG audit experience, working with ICD-10-CM/PCS, MS-DRG and APR-DRG preferred. Pediatric experience strongly preferred.
For the RHIA/RHIT/CCS a minimum 5 years of hospital inpatient coding experience, and 2 years of CDI or DRG audit experience, working with ICD-10-CM/PCS, MS-DRG and APR-DRG.
Knowledge and previous use of electronic health record is required.
Computer proficiency: recent working experience with Microsoft Outlook, Word, Excel and ability to navigate in a Windows based environment.
Ability to interact with physicians and adapt communication style.
Strong organization skills
Effective verbal and written communication skills critical thinking skills, ability to give presentations - Ability to take initiative, use sound judgment, work with tight deadlines and be flexible.
Licensure, Registration, and/or Certification:
Current Registered Nurse Licensure in the State of Texas;
CCS, RHIT, RHIA Certification. Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) are required to be obtained on or before the third (3) year hire date.
Internal Number: 51634-44018
About Cook Children's Health Care System
Cook Children's Health Care System is a not-for-profit, nationally recognized pediatric health care organization comprised of eight entities – a Medical Center, Physician Network, Home Health company, Northeast Hospital, Pediatric Surgery Center, Health Plan, Health Services Inc., and Health Foundation.Cook Children's Medical Center Based in Fort Worth, Texas, the integrated system has more than 60 primary and specialty care offices throughout North Texas. Its service region includes Denton, Hood, Johnson, Parker, Tarrant and Wise counties, with an additional referral area encompassing nearly half the state.Cook Children's traces its roots back to 1918, but throughout its continual change and robust growth, it still embraces an inspiring promise – to improve the health of every child in its region through the prevention and treatment of illness, disease and injury. To live up to this promise, Cook Children's combines the art of caring with the use of leading technology and extraordinary collaboration to provide exceptional care for every child, every day.History – Cook Children's has a rich history of nearly a century of caring for children.Our Promise – Knowing that every child's ...life is sacred, it is the promise of Cook Children's to improve the health of every child in our region through the prevention and treatment of illness, disease and injury.Companies – Based in Fort Worth, Texas, Cook Children's is a not-for-profit organization that is comprised of eight nationally recognized companies.Community Health Outreach – Cook Children's Community Health Outreach works together with over 150 partner organizations to improve the safety and health of at-risk children through education, disease and injury prevention and support.Clinical Research – Cook Children's is home to a skilled team of research-minded physicians, nurses and health care professionals and administrators who drive our commitment to excellent clinical care and the search for medical advances.Public Relations – Cook Children's Public Relations works with national and local media outlets, produces Cook Children's publications, coordinates special events and helps develop key relationships within the community.Contractor & Vendor Information – Cook Children's contractors and vendors must ensure their employees are knowledgeable about working with our organization.Sponsorship guidelines – Cook Children's sponsors a select number of events that are strongly aligned with its promise to improve the health of every child in the region through the prevention and treatment of illness, disease and injury.