Clinical Doc Improv Spec 1

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:

- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1

Note: Benefits may vary based upon position type and/or level.

Job Summary

Clinical Doc 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.

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.

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).