Clinical Documentation Integrity Analyst

Here’s What You Need

• Associate’s degree in nursing or HIM required
• Bachelor’s degree in nursing or HIM preferred
• 2 years experience as a clinical documentation specialist required
• 3 years experience as an RN in an acute care setting preferred
• 3 years experience in inpatient coding experience preferred
• RN ( valid current licensure in the state of Texas) upon hire required or
• RHIT  (valid current credentials with AHIMA) upon hire required or
• RHIA (valid current credentials with AHIMA) upon hire required or
• CCS (valid current credentials with AHIMA) upon hire required
•  CCDS or CSIP upon hire preferred

 

What You Will Do

Responsible for conducting ongoing analysis of clinical documentation while providing extensive collaboration with coding staff to improve quality and completeness of documentation of care provided and coded data.   Conduct ongoing audits of CDI staff, initiate corrective action to ensure resolution of problem areas identified.  Compile metrics and reports and serve as a subject matter expert on CDI, as well as CDI software used. 

Validations and Variances

 • Analyze, investigate and compare compliant documentation integrity (CDI).

 • Assess, reconcile and resolve discrepancies between CDI and HIM Coding related to principal diagnosis (PDX), complication or comorbidity (CC), major complication or comorbidity (MCC) or Diagnosis Related Group (DRG) assignment in a timely fashion.

 • Initiates and performs focused record reviews based on patterns and trends discovered.

Auditing

•Manage concurrent and retrospective audits of medical records to validate assignment of diagnosis, procedures and/or DRG.

•Assess appropriate code assignment of Principal diagnosis (PDX), complication or comorbidity (CC), major complication or comorbidity (MCC) or Diagnosis Related Group (DRG) assignment.

•At the conclusion of audits, have the ability to identify education opportunities and report findings to staff, management and educator, as appropriate.

•Recommend to the CDI educator programs for ongoing CDI education as it relates to proper clinical coding, capture of patient care, severity and the need for accurate and complete documentation in the health record.

Analysis

 • Analyze data to determine education deficiencies for providers and CDI staff.

 • Analyze data trends and advise management of patterns and trends.

 • Compile and collect metrics for CDI production, quality measures and time studies, as well as reports for analytical compilation and review of system and organizational initiatives as requested.

Subject Matter Expert

•Serves as a subject matter expert to CDI staff:

•Apply exceptional knowledge of all inpatient ICD-10 coding guidelines to determine accuracy of CDI reconciliation process, as well as MS and APR DRGs changes and updates.

•Demonstrates knowledge of denial issues for clinical validation opportunities, clinical documentation requirements, coding standards and compliance requirements.

Professional Accountability

•Maintains all requirement for certification and education for designated role.

•Assumes responsibility and accountability for incorporating the mission, vision, values and critical goals of the organization in to job performance.

•Perform other duties as assigned.

 

 

Additional perks of being a Texas Health Clinical Documentation Integrity Analyst

• Benefits include 401k, PTO, medical, dental, Paid Parental Leave, flex spending, tuition reimbursement, student Loan forgiveness as well as several other benefits.
• Delivery of high quality of patient care through nursing education, nursing research and innovations in nursing practice.
•  Strong Unit Based Council (UBC).
•   A supportive, team environment with outstanding opportunities for growth.
• Learn more about our culture, benefits, and recent awards.

Do you still have questions or concerns? Feel free to email your questions to recruitment@texashealth.org.

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