Clinical Documentation Integrity Specialist- Lead

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With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. At UT Southwestern, we invest in you with opportunities for career growth and development that align with your future goals and help to provide security for you and your family. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more that are all available on the day you start work. UT Southwestern is honored to be a Veteran Friendly work environment that is home to approximately 800 veterans. We value your integrity, dedication, and the commitment you've made to our country. We're proud to support your next mission. Ranked by Forbes as one of the Top 10 National Employers, we invite you to be a part of the UT Southwestern team where you'll discover teamwork, professionalism, and consistent opportunities for growth. The #1 Best Hospital in DFW | UT Southwestern Medical Center (utswmed.org)

The Lead CDI Specialist will lead and manage special projects that require CDI resources; from testing through implementation and training. Validate results from Quality and Compliance reviews to ensure clinical evidence supports what was coded and billed. The CDI Lead acts as the first level subject matter expert, mentor, and liaison for the CDI, Coding, and Quality Teams. Works collaboratively with, and is a liaison to other Departments, Leadership, Service Line Champions, Physicians, and other members of the Healthcare Team. Trains new CDI Staff on CDI concepts, processes, and policies to ensure compliance with organizational, departmental, and regulatory requirements. The CDI Lead may be asked to mentor and precept new CDI Specialists as well as more experienced CDI Specialists.

Experience and Education

• RN Licensure required. BSN preferred
• Required - 5 years acute care Hospital nursing experience, preferred in critical care
• Required - 3 years of experience working in a Clinical Documentation Integrity program; An equivalent combination of education and experience may be considered
• Required - Certification: (CCDS) Certified Clinical Documentation Specialist, or (CDIP) Certified Documentation Improvement Practitioner; or must attain CCDS or CDIP within 6 months after eligibility requirements are met
• Must be proficient with computers, and have a working knowledge of 3M 360 & Epic, or similar electronic systems
• Experience working in a remote environment preferred

Job Duties

1. Acts as the first level resource, mentor, and liaison for the CDI, Coding, and Quality Teams.
2. Trains CDI Staff on CDI concepts, processes, and policies, in compliance with organizational, departmental, and regulatory requirements
3. Responsible for overseeing special projects; i.e. testing, implementation, training, etc.
4. Mentor and preceptor for new CDI Specialists as well as more experienced CDI Specialists
5. Perform second level clinical reviews for high impact targeted metrics, including but not limited to Mortalities, PSI's, DRG Mismatch, and Compliance
6. May perform CDI quality audits to monitor for query compliance, workflow strategies for prioritization, completion of CDI worksheet, and appropriate engagement with Physicians and the Healthcare Team, to assure the level of services provided and the acuity of care are accurately reflected in the record
7. May provide backup for CDI Specialist duties as needed
8. Support the Quality Standards set by UTSW and the HIM Coding & CDI Department
9. Maintains an expert level of knowledge of CDI related guidelines and practices.
10. Performs other duties as assigned

• Work requires organizational skills along with a high level of accuracy and attention to detail
• Work requires the ability to set priorities and reprioritize as needed to meet project deadlines, etc.
• Work requires excellent customer service, interpersonal, and communication skills (verbal and written)
• Work requires ability to handle multiple tasks, show initiative, and quickly adapt to changes as necessary
• Work requires strong analytical and critical thinking skills
• Work requires ability to report and problem solve using discretion, judgment, and professionalism.
• Work requires ability to perform in a conservative, fast-paced, and quality driven environment.
• Work requires ability to comprehend, understand, and follow established policies, procedures, and other guidelines of some complexity
• Work requires self-motivation, maturity, and being a team player

• Full mobility with ability to participate in vigorous activity
• Must be able to walk reasonable distances to cover multiple nursing units and travel between (2) Hospitals, via Campus Shuttle; and work in an office environment.

This job is Majority Remote, >=80%

UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include:
• PPO medical plan, available day one at no cost for full-time employee-only coverage
• 100% coverage for preventive healthcare - no copay
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer
• Learn more about these and other UTSW employee benefits!