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UT Health Specialist, Clinical Documentation Improvement in Texas Medical Center-Houston, Texas

Specialist, Clinical Documentation Improvement

Texas Medical Center-Houston, Texas


McGovern Medical School at UTHealth

Requisition #: 2200002G

Position Summary:

The Clinical Documentation Improvement Specialist (CDIS), working under the direction of the Manager, CDI, utilizes compliant documentation improvement principles and coding expertise to identify areas of opportunity that impact the quality and the completeness of the medical record documentation. Through current, prospective, and retrospective evaluation of the medical record documentation, the CDIS will be responsible for working collaboratively with the billing providers to clarify documentation, support medical necessity, and provide education with the end goal of achieving improved documentation results and reduction of unnecessary denials for the organization. The CDIS will determine and initiate CDI program services.

Position Key Accountabilities:

  1. Identifies service areas or individual providers that would benefit from the CDI program based on CDI audits.

  2. Works collaboratively with the coding team and billing compliance to determine needed CDI resources in identified risk areas.

  3. Effectively communicates, educates and audits patient records for program effectiveness.

  4. Responsible for ensuring provider CDI query compliance and providing feedback to the medical staff and applicable department leadership participating in the CDI program.

  5. Provides CDI program education to billing provider and coders.

  6. Tracks and provides metric data for program effectiveness to CDI Manager.

  7. Performs other duties as assigned.


Must possess one or more of the following: Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P)

Must be willing to certify in CDI within 1 year of hire.

Analytical skills, ability to interpret data, and generate reports, overall turning valuable data into presentable information for providers

Proficiency in Microsoft Office suite

The ability to abstract data and maintain a database

Outpatient Auditor experience is preferred

EPIC experience is preferred

Previous leadership or provider education experience is preferred

Minimum Education:

Associates degree is required.

Minimum Experience:

Minimum of five (5) years of experience in a combination of outpatient coding and clinical documentation improvement roles located in an outpatient or large provider office setting.

Physical Requirements:

Exerts up to 20 pounds of force occasionally and/or up to 10 pounds frequently and/or a negligible amount constantly to move objects.

Security Sensitive:

This job class may contain positions that are security sensitive and thereby subject to the provisions of Texas Education Code § 51.215

If you are looking for a great healthcare career in Houston, visithttp://go.uth.edu/careers!

University of Texas Health Science Center at Houston (UTHealth)

Established in 1972 by The University of Texas System Board of Regents, The University of Texas Health Science Center at Houston (UTHealth) is Houston’s Health University and Texas’ resource for health care education, innovation, scientific discovery and excellence in patient care. The most comprehensive academic health center in the UT System and the U.S. Gulf Coast region, UTHealth is home to schools of biomedical informatics, biomedical sciences, dentistry, nursing and public health and the John P. and Kathrine G. McGovern Medical School. UTHealth includes The University of Texas Harris County Psychiatric Center, as well as the growing clinical practices UT Physicians, UT Dentists and UT Health Services. The university’s primary teaching hospitals are Memorial Hermann-Texas Medical Center, Children’s Memorial Hermann Hospital and Harris Health Lyndon B. Johnson Hospital.

UTHealth Benefits

UTHealth offers a comprehensive and competitive benefits package. For more information on our benefits programs please refer to the UTHealth Office of Benefits Website.


Equal Employment Opportunity Statement

UTHealth is committed to providing equal opportunity in all employment-related activities without regard to race, color, religion, sex, sexual orientation, national origin, age, disability, genetic information, gender identity or expression, veteran status or any other basis prohibited by law or university policy. Reasonable accommodation, based on disability or religious observances, will be considered in accordance with applicable law and UTHealth policy. The University maintains affirmative action programs with respect to women, minorities, individuals with disabilities, and eligible veterans in accordance with applicable law.