Clinical Documentation Improvement Specialist - Part Time Job

Children's Health - Health Information Careers

Job Number: 51412

Location: Dallas, TX

Date Posted: 2-15-2017



Facilitates and obtains appropriate provider documentation for clinical conditions and/or procedures to support the appropriate APR-DRG assignment, severity of illness, expected risk of mortality, and complexity of care provided to patients.


Completes initial concurrent reviews of patient records for specified patient populations to evaluate documentation, to assign working DRG, pertinent secondary diagnoses and procedures for accurate APR-DRG assignment, risk of mortality and severity of illness

Educates physicians and providers regarding the need for accurate and complete documentation in the health record.

Partners with coding professionals to ensure accuracy of diagnostic and procedure data and completeness of supporting documentation to determine appropriate APR-DRG assignment

Queries physicians regarding missing, unclear or conflicting health record documentation

Requires experience in own professional discipline to appropriately apply own knowledge; broadens own professional expertise and acquires higher level skills

Understands key business drivers; uses this understanding to accomplish own work

No supervisory responsibilities but may provide informal guidance to new team members

Solves problems in straightforward situations; analyzes possible solutions using professional/technical experience, judgment and precedents

Impacts quality of own work and the work of others on the team; works within guidelines and policies

Receives a moderate level of guidance and direction

Explains complex information to others in straightforward situations


Minimum 1-2 years of job related experience, required

Equivalent combination of education and/or experience in Health Information Management, Healthcare Administration, Healthcare Operations, Coding, Nursing, Case Management, or experience as a Physician, preferred


Four-year Bachelor's degree or equivalent experience, required

Graduate or professional work or advanced degree; or equivalent experience, preferred


Licensed medical doctor, preferred

Licensed registered nurse, preferred

Registered Health Information Management Technician / Administrator, preferred


Light - Exerting up to 20 lbs. occasionally, 10 lbs. frequently, or negligible amounts constantly and may require walking or standing to a significant degree.

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