HIM CDI Specialist II

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, CPT, SOI/ROM 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– –
•    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 coding 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 inpatient coding experience working with the coding classification systems, medical terminology, anatomy and physiology and disease processes.
•    RN/HIM Professionals must have Two plus (2+) years of experience working in clinical documentation integrity

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 Integrity Practitioner (CDIP) certification is required.

Required Tests for Placement

•   None

Skills or Special Abilities
•    Organizational, analytical, writing and interpersonal skills.
•    Must be able to be comfortable speaking and teaching in group settings
•    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.
•    Must have 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 unassiged duties in accordance with the current State of Texas Nurse Practice Act.

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 95% of identified populations.
2.    Conducts initial and extended-stay concurrent reviews on all selected inpatient 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.    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.
5.    Provides information and in-services as necessary to physician and ancillary staff.

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. As part of our commitment to our patients and employees’ wellness, Parkland Health is a tobacco and smoke-free campus.