Clinical Documentation Specialist | Cook Children's Health Care System

Cook Children's Health Care System

Fort Worth, Texas, Summary 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.

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