About The Role

The Clinical Documentation Integrity (CDI) Specialist Associate provides support and expertise by assessing and reviewing inpatient medical records to ensure documentation reflects diagnosis and treatment. Collaborates with providers, patient caregivers, quality department, and medical coding to ensure appropriate DRG assignment. Facilitates modifications to the medical record documentation to accurately reflect the patient’s severity of illness, risk of mortality, and DRG. Supports and maintains UT Health San Antonio policies, protocols, and values. Works under the general supervision of the CDI Manager in a hospital setting.

Responsible for the day-to-day evaluation of documentation by medical staff and patient caregivers.
Ensure the accuracy and completeness of clinical information used for reporting severity of illness, risk of mortality, DRG and hospital outcomes.
Using expert clinical knowledge, initiate compliant and effective verbal and written queries for points of clarification of the documentation in the medical record.
Conducts follow-up reviews of clinical documentation to ensure the completeness and consistency of the level of care provided to the patient.
Tracks and escalates HAC and HARM quality measures.
Assists with clinical validation reviews related to the denials and appeals process.
Assists CDI supervisor with developing provider education strategies to promote complete, accurate, and comprehensive medical record documentation.
Assists with mentoring or training new Clinical Documentation Integrity Specialists.
Analyzes data and reports quality issues to CDI Supervisor.
Supports meeting organizational unbilled goals for Accounts Receivable with uncoded accounts.
Performs all aspects of daily work in a manner that contributes to and ensures an environment of strict confidentiality.
Performs all other duties as assigned.
Knowledge of Official Guidelines for coding and reporting.
Knowledge of medical terminology, human anatomy, physiology and pharmacology.
Knowledge of disease pathology.
Knowledge of ICD-10-CM/PCS.
Knowledge of DRG payor regulations, documentation opportunities, and clinical documentation requirements.
Ability to interpret data in order to improve documentation practices.
Knowledge of operating ordinary business equipment in a remote and office environment, such as computers, keyboards, and telephones.
Ability to work effectively in and navigate between common office software, coding software, billing software, and abstracting systems. Knowledge of coding resources and demonstrated proficiency in using resources.
Ability to troubleshoot basic technical issues in the remote and office environment.
Ability to communicate effectively with providers and patient care givers.
REQUIRED QUALIFICATIONS: RN, RHIT, RHIA, CDIP, or CCDS.