The Clinical Documentation Improvement Specialist (CDIS) applies clinical knowledge to analyze and to interpret health records. Proficiently applies ICD-10 coding to in-house patients. Analyzes records for optimization of physician documentation and query potential if required. Provides education to providers, coders, case management and interacts with other departments as required. Tracks pre and post DRG data. Performs varied, difficult and specialized tasks without detailed guidance, is expected to exercise judgment and apply expert knowledge. MINIMUM SPECIFICATIONS Education: ¿Must have a degree in nursing from an accredited college or university. ¿OR¿ ¿Master¿s Degree in a Healthcare/Medical related field from an U.S. accredited college or university ¿OR¿ ¿Graduated from an accredited Health Information Management program. Experience: ¿For RNs: 3 plus years of clinical experience in an acute care setting (ICU/Critical Care / Surgery Specialty) ¿For HIM Professionals: Must have 2 plus years of experience working with the coding classification systems, medical terminology, anatomy and physiology and disease processes. . ¿OR¿ ¿2 years of inpatient coding experience Equivalent Experience: ¿May have an equivalent combination of education and experience to substitute for both the education and the experience requirements. Certification/Registration/Licensure: ¿New hires must have one of the following current certifications or must be obtain within two years from the date of hire. o Certified Clinical Documentation Specialists (CCDS) o Certified Documentation Improvement Practitioner (CDIP) ¿Current incumbents hired on or before 10/1/2017 must have one of the following current certifications or must be obtain by 10/1/2019. o Certified Clinical Documentation Specialists (CCDS) o Certified Documentation Improvement Practitioner (CDIP) ¿OR¿ ¿Current incumbents hired after 10/1/2017 must have one of the following current certifications or must be obtain within two years from the date of hire. o Certified Clinical Documentation Specialists (CCDS) o Certified Documentation Improvement Practitioner (CDIP) ¿For RNs Only: Must have current RN license or valid temporary permit with the Texas Board of Nursing; or, valid Compact RN license. ¿For HIM Professionals Only: Must have current Certified Coding Specialists (CCS), or ¿Registered Health Information Technology (RHIT), or ¿Registered Health Information Management Administrator (RHIA). Skills or Special Abilities: ¿Organizational, analytical, writing and interpersonal skills. ¿Must be able to be comfortable teaching in group settings as a large part of the job is educating healthcare providers about current documentation standards and helping them appreciate their role in documentation improvement. ¿Must possess expert knowledge of medical terminology, anatomy & physiology and ICD-10 and CPT coding principles. ¿Must be able to communicate effectively with physicians, nursing and ancillary staff. ¿Must be able to demonstrate patient centered/patient valued behaviors. ¿Must demonstrate knowledge and skill in age specific needs and the elements of disease processes and related procedures. ¿Prefer applicant has knowledge of ICD-10-CM and ICD-10-CM/PCS coding conventions and/or clinical auditing processes. ¿Must be able to demonstrate a working knowledge of MS Office software, including Word, Excel, and PowerPoint. For RN applicants: ¿RN applicants must maintain standards of professional conduct and performs all assigned and unassigned duties in accordance with the current State of Texas Nurse Practice Act. ¿RN Applicants must pass Medication Examination prior to hospital orientation. Current Parkland employees requesting reassignment to role must have current Medication Examination on file.
Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.
Nearest Major Market: Dallas
Nearest Secondary Market: Fort Worth
Job Segment: Medical Coding, Physiology, Medical, Nursing, Patient Care, Healthcare