U
Hospital - CDI Specialist, Associate
UT Health San Antonio
10 hours ago
Full-time
On-site
San Antonio, Texas, United States
Registered Nurse
The Clinical Documentation Integrity (CDI) Specialist Associate provides support
and expertise by assessing and reviewing inpatient medical records to ensure
documentation reflects diagnosis and treatment. Collaborates with providers,
patient caregivers, quality department, and medical coding to ensure appropriate
DRG assignment. Facilitates modifications to the medical record documentation to
accurately reflect the patient’s severity of illness, risk of mortality, and
DRG. Supports and maintains UT Health San Antonio policies, protocols, and
values. Works under the general supervision of the CDI Manager in a hospital
setting.
RESPONSIBILITIES
* Responsible for the day-to-day evaluation of documentation by medical staff
and patient caregivers.
* Ensure the accuracy and completeness of clinical information used for
reporting severity of illness, risk of mortality, DRG and hospital outcomes.
* Using expert clinical knowledge, initiate compliant and effective verbal and
written queries for points of clarification of the documentation in the
medical record.
* Conducts follow-up reviews of clinical documentation to ensure the
completeness and consistency of the level of care provided to the patient.
* Tracks and escalates HAC and HARM quality measures.
* Assists with clinical validation reviews related to the denials and appeals
process.
* Assists CDI supervisor with developing provider education strategies to
promote complete, accurate, and comprehensive medical record documentation.
* Assists with mentoring or training new Clinical Documentation Integrity
Specialists.
* Analyzes data and reports quality issues to CDI Supervisor.
* Supports meeting organizational unbilled goals for Accounts Receivable with
uncoded accounts.
* Performs all aspects of daily work in a manner that contributes to and
ensures an environment of strict confidentiality.
* Performs all other duties as assigned.
QUALIFICATIONS
* Knowledge of Official Guidelines for coding and reporting.
* Knowledge of medical terminology, human anatomy, physiology and pharmacology.
* Knowledge of disease pathology.
* Knowledge of ICD-10-CM/PCS.
* Knowledge of DRG payor regulations, documentation opportunities, and clinical
documentation requirements.
* Ability to interpret data in order to improve documentation practices.
* Knowledge of operating ordinary business equipment in a remote and office
environment, such as computers, keyboards, and telephones.
* Ability to work effectively in and navigate between common office software,
coding software, billing software, and abstracting systems. Knowledge of
coding resources and demonstrated proficiency in using resources.
* Ability to troubleshoot basic technical issues in the remote and office
environment.
* Ability to communicate effectively with providers and patient care givers.
* REQUIRED QUALIFICATIONS: RN, RHIT, RHIA, CDIP, or CCDS.
EDUCATION:
HS Diploma or GED
Must have Clinical Experience
The University of Texas at San Antonio (UT San Antonio) is a nationally
recognized, top-tier public research university that unites the power of higher
education, biomedical discovery and healthcare within one visionary institution.
As the third-largest research university in Texas and a Carnegie R1-designated
institution, UT San Antonio is a model of access and excellence — advancing
knowledge, social mobility and public health across South Texas and beyond. UT
San Antonio serves approximately 42,000 students in 320 academic programs
spanning science, engineering, medicine, health, liberal arts, AI,
cybersecurity, business, education and more. With 17,000 faculty and staff, UT
San Antonio has been recognized by Forbes as one of America’s Best Employers for
Company Culture.
Benefits Overview
UT Health San Antonio offers an excellent benefits package for its employees.
Employees who work at least 20 hours a week, with an appointment of at least 4.5
months, are eligible for benefits.
Medical - UT SELECT Medical insurance is offered free for employees and
administered by Blue Cross and Blue Shield of Texas. Family members can be added
to the plan through payroll deduction. Employees and their dependents can also
receive discounted copays and coinsurance when using UT Health Physicians, a
network of 800 premier physicians including more than 100 specialists. Employees
receive $50,000 of group term life insurance and $50,000 of basic accidental
death and dismemberment insurance for free, with options to purchase additional
employee and dependent coverage for both at group rates.
Dental - Three dental insurance plan options are available for employees and
their families through Delta Dental Insurance Company, two PPOs and one dental
HMO plan. Both PPO plans allow employees to choose any licensed dentist.
Vision - Fully insured Vision Care benefits are offered by Superior Vision
Services. Two vision plan options that offer either standard or enhanced vision
benefits.
Disability - Employees can enroll in the Disability Insurance which provides
income if a non-work related illness or injury prevents you from working.
FSAs - Employees can enroll in flexible spending accounts (FSAs) to set aside
money from earnings before taxes for qualifying dependent day care expenses or
out-of-pocket health care expenses.
Retirement - Employees are eligible for either the Teacher Retirement System
(TRS) or the Optional Retirement Plan (ORP). TRS is a defined benefit retirement
plan which UT Health matches employee contributions. ORP is for eligible faculty
staff employees. Voluntary retirement programs are also available to invest
before- or after-tax dollars with the choice of five quality retirement plan
providers.
Time Off - A generous leave program offers multiple paid leave options:
* Front-loaded Paid Time Off: 128 to 208 hours (16 to 26 days) of Paid Time Off
based on years of service, given at the start of each fiscal year. PTO may be
prorated in year one based on date of hire.
* Extended Illness Bank: 8 hours (1 day) accrued per month which can be used
for illness or injury after one day of Paid Time Off is taken.
* Paid Family Leave: Up to 240 hours (6 weeks) to care for a spouse, child, or
parent after 6 months of consecutive employment.
* Holidays: 12 set paid holidays each year.
Discounts - Employees enjoy a range of discounts on services, tickets, and gym
membership.
EEO Statement
UT Health San Antonio is an equal employment opportunity and affirmative action
employer. It is our policy to promote and ensure equal employment opportunity
for all individuals without regard to race, color, religion, sex, gender
identity, national origin, age, sexual orientation, disability, or veteran
status.
and expertise by assessing and reviewing inpatient medical records to ensure
documentation reflects diagnosis and treatment. Collaborates with providers,
patient caregivers, quality department, and medical coding to ensure appropriate
DRG assignment. Facilitates modifications to the medical record documentation to
accurately reflect the patient’s severity of illness, risk of mortality, and
DRG. Supports and maintains UT Health San Antonio policies, protocols, and
values. Works under the general supervision of the CDI Manager in a hospital
setting.
RESPONSIBILITIES
* Responsible for the day-to-day evaluation of documentation by medical staff
and patient caregivers.
* Ensure the accuracy and completeness of clinical information used for
reporting severity of illness, risk of mortality, DRG and hospital outcomes.
* Using expert clinical knowledge, initiate compliant and effective verbal and
written queries for points of clarification of the documentation in the
medical record.
* Conducts follow-up reviews of clinical documentation to ensure the
completeness and consistency of the level of care provided to the patient.
* Tracks and escalates HAC and HARM quality measures.
* Assists with clinical validation reviews related to the denials and appeals
process.
* Assists CDI supervisor with developing provider education strategies to
promote complete, accurate, and comprehensive medical record documentation.
* Assists with mentoring or training new Clinical Documentation Integrity
Specialists.
* Analyzes data and reports quality issues to CDI Supervisor.
* Supports meeting organizational unbilled goals for Accounts Receivable with
uncoded accounts.
* Performs all aspects of daily work in a manner that contributes to and
ensures an environment of strict confidentiality.
* Performs all other duties as assigned.
QUALIFICATIONS
* Knowledge of Official Guidelines for coding and reporting.
* Knowledge of medical terminology, human anatomy, physiology and pharmacology.
* Knowledge of disease pathology.
* Knowledge of ICD-10-CM/PCS.
* Knowledge of DRG payor regulations, documentation opportunities, and clinical
documentation requirements.
* Ability to interpret data in order to improve documentation practices.
* Knowledge of operating ordinary business equipment in a remote and office
environment, such as computers, keyboards, and telephones.
* Ability to work effectively in and navigate between common office software,
coding software, billing software, and abstracting systems. Knowledge of
coding resources and demonstrated proficiency in using resources.
* Ability to troubleshoot basic technical issues in the remote and office
environment.
* Ability to communicate effectively with providers and patient care givers.
* REQUIRED QUALIFICATIONS: RN, RHIT, RHIA, CDIP, or CCDS.
EDUCATION:
HS Diploma or GED
Must have Clinical Experience
The University of Texas at San Antonio (UT San Antonio) is a nationally
recognized, top-tier public research university that unites the power of higher
education, biomedical discovery and healthcare within one visionary institution.
As the third-largest research university in Texas and a Carnegie R1-designated
institution, UT San Antonio is a model of access and excellence — advancing
knowledge, social mobility and public health across South Texas and beyond. UT
San Antonio serves approximately 42,000 students in 320 academic programs
spanning science, engineering, medicine, health, liberal arts, AI,
cybersecurity, business, education and more. With 17,000 faculty and staff, UT
San Antonio has been recognized by Forbes as one of America’s Best Employers for
Company Culture.
Benefits Overview
UT Health San Antonio offers an excellent benefits package for its employees.
Employees who work at least 20 hours a week, with an appointment of at least 4.5
months, are eligible for benefits.
Medical - UT SELECT Medical insurance is offered free for employees and
administered by Blue Cross and Blue Shield of Texas. Family members can be added
to the plan through payroll deduction. Employees and their dependents can also
receive discounted copays and coinsurance when using UT Health Physicians, a
network of 800 premier physicians including more than 100 specialists. Employees
receive $50,000 of group term life insurance and $50,000 of basic accidental
death and dismemberment insurance for free, with options to purchase additional
employee and dependent coverage for both at group rates.
Dental - Three dental insurance plan options are available for employees and
their families through Delta Dental Insurance Company, two PPOs and one dental
HMO plan. Both PPO plans allow employees to choose any licensed dentist.
Vision - Fully insured Vision Care benefits are offered by Superior Vision
Services. Two vision plan options that offer either standard or enhanced vision
benefits.
Disability - Employees can enroll in the Disability Insurance which provides
income if a non-work related illness or injury prevents you from working.
FSAs - Employees can enroll in flexible spending accounts (FSAs) to set aside
money from earnings before taxes for qualifying dependent day care expenses or
out-of-pocket health care expenses.
Retirement - Employees are eligible for either the Teacher Retirement System
(TRS) or the Optional Retirement Plan (ORP). TRS is a defined benefit retirement
plan which UT Health matches employee contributions. ORP is for eligible faculty
staff employees. Voluntary retirement programs are also available to invest
before- or after-tax dollars with the choice of five quality retirement plan
providers.
Time Off - A generous leave program offers multiple paid leave options:
* Front-loaded Paid Time Off: 128 to 208 hours (16 to 26 days) of Paid Time Off
based on years of service, given at the start of each fiscal year. PTO may be
prorated in year one based on date of hire.
* Extended Illness Bank: 8 hours (1 day) accrued per month which can be used
for illness or injury after one day of Paid Time Off is taken.
* Paid Family Leave: Up to 240 hours (6 weeks) to care for a spouse, child, or
parent after 6 months of consecutive employment.
* Holidays: 12 set paid holidays each year.
Discounts - Employees enjoy a range of discounts on services, tickets, and gym
membership.
EEO Statement
UT Health San Antonio is an equal employment opportunity and affirmative action
employer. It is our policy to promote and ensure equal employment opportunity
for all individuals without regard to race, color, religion, sex, gender
identity, national origin, age, sexual orientation, disability, or veteran
status.