Texas Licensed CDI Specialist

Job Summary

Providing expertise in clinical documentation, the full-time Texas Licensed CDI Specialist will assess and review inpatient medical records remotely to ensure accurate documentation of diagnoses and treatments while collaborating with healthcare providers and coding teams.

Key responsibilities

• Evaluate medical documentation for accuracy and completeness, ensuring it reflects the patient's severity of illness and risk of mortality
• Initiate compliant queries for clarification of documentation and conduct follow-up reviews to maintain consistency in patient care records
• Assist in developing provider education strategies and mentor new Clinical Documentation Integrity Specialists

Required qualifications

• Texas Licensed RN, RHIT, RHIA, CDIP, or CCDS
• Knowledge of Official Guidelines for coding and reporting, ICD-10-CM/PCS, and DRG payor regulations
• Clinical experience with medical terminology, human anatomy, physiology, and pharmacology
• Experience in medical records abstraction and coding in an acute care setting
• Proficiency in using coding and billing software, with familiarity in EPIC and 3M encoder software preferred