Laredo Medical Center is looking for a Clinical Documentation Improvement Specialist (CDIS). The Clinical Documentation Improvement Specialist implements clinical documentation improvement (CDI) activities in an effort to support accuracy and quality of the patient records at CHS facilities and to ensure that coded diagnoses are an accurate reflection of the patient’s clinical status and care. The role of the CDI specialist involves reviewing the medical record documentation and clinical indicators and working with providers to ensure a complete and accurate medical record. An accurate medical record is important for the patient, for continuity of care by the next provider, and to demonstrate high quality care by the physician and the hospital. The CDI Specialist will identify potential gaps in clinical documentation for inpatient and payer populations as directed throughout the hospitalization. He/she will also educate physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record. This position will be reporting to the CFO.

Education:

Required:

BSN, RN, or comparable clinical degree

Preferred:

RHIT, RHIA, CDIP, CCDS, CCS and ICD-10 certification or designation

Experience

Required:

• Must possess at least five years of acute hospital nursing experience (e.g. medical/surgical unit, intensive care).
• This individual must possess a comprehensive knowledge of medical terminology, disease processes and clinical competency.
• Candidate must possess excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills.
• Strong critical thinking skills and ability to integrate knowledge is necessary.
• Prioritization and organizational skills required.
• Must exhibit the ability to educate members of the healthcare team about clinical documentation.
• Individual must demonstrate data quality and integrity skills

Preferred:

• Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management and/or inpatient coding.
• ICU/Critical Care
• Clinical documentation improvement, ICD coding and MS-DRGs
• Educating physicians/providers
• Working in a clinical documentation improvement department or as a consultant.
• Minimum of one-year auditing

Job Qualifications:

• Currently licensed to practice as a Registered Nurse or Licensed Vocational Nurse by the Texas State Board of Nurse Examiners.