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Posted: Sunday, May 28, 2017 1:51 PM

Clinical Documentation Improvement Specialist

Medical City Healthcare Division

Schedule: Full Time Days

Available Positions:

  • Medical City Alliance/Las Colinas and other locations as needed
General Responsibilities
  • Practices and adheres to the “Code of Conduct” philosophy and “Mission and Value Statement”
  • Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, and other patient caregivers to ensure that the documentation of the level of service rendered to the patient and the patient’s clinical complexity is complete and accurate
  • Reviews medical records and identifies potential gaps in clinical documentation
  • Performs a thorough chart review to identify that the Principal diagnosis, present on admission (POA) indicators and co-morbidities/complications are documented appropriately
  • Assigns concurrent MS-DRGs for identified populations by conducting initial and re-reviews
  • Queries physicians using approved query forms for missing, unclear, or conflicting documentation by requesting and obtaining additional documentation within the health record to obtain accurate and complete documentation that supports the severity of patient illness and risk of mortality
  • Interacts with physicians to resolve queries prior to patient discharge
  • Collaborates with case managers, nursing staff, and other ancillary staff to help resolve physician queries prior to patient discharge
  • Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record; provides formal and informal in-services as needed to physicians and ancillary staff
  • Participates in the analysis and trending of statistical data to identify opportunities for improvement
  • Identifies strategies for work process changes that facilitate complete, accurate clinical/physician documentation
  • Documents reviews and other pertinent information concurrently by the established deadlines
  • Documents reviews and other pertinent information post discharge by the established deadlines
  • Works closely with designated Health Information Service Center (HSC) coding staff to assure documentation of discharge diagnoses and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care
  • Reviews HSC coding feedback as a means of continuous education and self-evaluation
  • Reviews HSC coding post discharge query trending as a means of concurrent physician interaction opportunities
  • Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership
  • Demonstrates ongoing knowledge of clinical requirements and coding standards for evaluation of medical record documentation
  • Completes all assigned education by the established deadlines
  • Provides coverage for other CDI staff
  • Assists with training CDI staff
  • Maintains the ability to be flexible and prioritize daily responsibilities
  • Other duties as assigned

About Medical City Healthcare


Medical City Healthcare is one of the region’s largest, most comprehensive health care providers and includes 16 hospitals, 7 freestanding emergency rooms, more than 50 ambulatory sites, more than 7,000 active physicians and 15,000 employees in the Dallas-Fort Worth and Oklahoma City areas. Medical City Healthcare is distinguished as the first regional brain attack network in the United States, with four comprehensive stroke centers, and six primary stroke centers geographically positioned to provide rapid access to high quality stroke care across the region. Five Medical City Healthcare hospitals hold the prestigious Magnet Recognized® status from the American Nurses Association — a designation of quality achieved only by the top 5 percent of hospitals nationwide. Eight Medical City Healthcare hospitals are on The Joint Commission’s 2014 list of Top Performers on Key Quality Measures™.


Click here for more info: https://hca.taleo.net/careersection/0hca/jobdetail.ftl?job=09375-90092&lang=en


• Location: Coppell, North DFW

• Post ID: 49351171 northdfw
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