Clinical Documentation Improvement (CDI) Specialist - Rev Cycle at UTHealth in Houston, Texas

Job Description:

Position Summary:

The Clinical Documentation Improvement (CDI) Education Specialist reports to the CDI Director and is accountable for ensuring providers are documenting and coding encounters and procedures in the Inpatient, Outpatient and Clinic setting to meet Professional Billing requirements. The goal is to create and provide provider education that results in improved documentation and coding accuracy across the organization. This position collaborates and works closely with Coding and Charge Capture and Billing Compliance leadership to identify specific areas and providers in need of CDI education.

We are seeking a highly skilled and motivated Specialist in Clinical Documentation Improvement (CDI) Education to join our dynamic healthcare team. The ideal candidate will possess extensive knowledge in medical coding, billing, and clinical documentation standards. This role involves educating healthcare providers on best practices for accurate and comprehensive documentation, ensuring compliance with healthcare regulations, and optimizing patient outcomes. Strong communication and analytical skills are essential, as the specialist will collaborate with various healthcare professionals to identify and address documentation gaps

• 
  Department: Revenue Cycle
• 
  Status: Full-time
• 
  Location: Remote (2 -4 weeks onsite for training @ 1851 Crosspoint Ave, 77054) meetings, additional training, etc.).
• 
  Must live in Texas (TX) This is a Remote position, and you must reside in Texas


• 
  Must be able to attend any required onsite meetings

Position Key Accountabilities:

1. Responsible for the ongoing development, creation and maintenance of individual education projects and resources to include: stakeholder meetings, scheduling education sessions, preparing materials and formal presentations.
2. Collaborates with Billing Compliance and Coding on team identified projects. Utilizes all CDI functionality defined in our scope of practice to find resolution to provider issues. The team is responsible for delivery of provider findings, resources and education material. Researches new services and creates CDI Resources to ensure provider success with new billing opportunities across the organization.
3. Identifies service areas or individual providers in need of CDI and audits encounter notes. Ensures documentation compliance and completeness of the medical record documentation in order to provide documentation and coding accuracy. Effectively communicates and personally educates providers.
4. Creates CDI education material for utilization in New Provider Orientation.
5. Ensures effective project tracking, dissemination and communication of all CDI project education efforts to all members of Revenue Cycle, Coding and Billing Compliance.
6. Serves as a SME on CDI scope of practice during internal and external meetings as required.
7. Other duties as assigned.

Certification/Skills:

Must possess one or more of the following: Certification as a Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), OR Certified Coding Specialist-Physician-based (CCS-P). Clinical Documentation Improvement Certification required, but the certification may be obtained within one year of employment. Certified Instructor/Educator credentials preferred. Proficiency in Microsoft Office suite, presentation software and internet communication programs. Analytical skills, ability to interpret data, and generate reports, overall turning valuable data into presentable information for providers. Demonstrates strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues. Excellent time management skills required, self-motivated and able to work independently without close supervision, and ability to work effectively under pressure due to changing priorities, interruptions, and workload variability.

Minimum Education:

Associate's degree or equivalent combination of education and experience; bachelor's degree preferred.

Minimum Experience:

Three years of coding, billing compliance and/or CDI education experience, with at least 2 years of experience as a pro-fee coder/auditor and/or healthcare billing compliance or clinical documentation improvement experience. Experience with EPIC is preferred.

Physical Requirements:

Exerts up to 20 pounds of force occasionally and/or up to 10 pounds frequently and/or a negligible amount constantly to move objects.

Security Sensitive:

This job class may contain positions that are security sensitive and thereby subject to the provisions of Texas Education Code § 51.215

Residency Requirement:

Employees must permanently reside and work in the State of Texas.