Clinical Documentation Improvement (CDI) Specialist Job Listing at Emerus Holdings Inc. in Houston, TX (Job ID 2024-19544)

Description

The CDI Specialist will be responsible for improving the overall quality and completeness of clinical documentation. This role requires significant experience in CDI, as the specialist will be the sole member of the department. The ideal candidate will be adept at creating and establishing processes, working independently, and collaborating with healthcare providers to ensure accurate and comprehensive patient records.

• Bachelor's degree in Nursing, Health Information Management, or a related field.
• Certified Clinical Documentation Specialist (CCDS) or similar certification preferred.
• Minimum of 5 years of experience in clinical documentation improvement.
• Strong understanding of medical terminology, coding standards, and regulatory requirements.
• Excellent communication and interpersonal skills.
• Ability to work independently and establish effective processes.
• Proficiency with CDI software and electronic health records (EHR) systems.

• Develop and implement CDI processes and protocols tailored to our med/tele and ED patient populations.
• Conduct thorough reviews of clinical documentation to ensure accuracy, completeness, and compliance with regulatory standards.
• Collaborate with physicians, nurses, and other healthcare providers to clarify documentation and ensure it accurately reflects patient care.
• Educate and train clinical staff on best practices for documentation improvement.
• Utilize CDI software and tools to track and analyze documentation trends and outcomes.
• Prepare and present regular reports on CDI activities and outcomes to senior management.
• Stay current with industry standards, regulatory requirements, and best practices in clinical documentation.

• Attend staff meetings or other company sponsored or mandated meetings as required
• Travel to all facility locations as required
• Perform additional duties as assigned
• Ability to work off-hours when required