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CDI Specialist, Associate
Margie and Bill Klesse College of Engineering and Integrated Design at UTSACDI Specialist reviewing hospital records to clarify diagnoses, severity, and DRG assignment. Supporting providers, coding, quality reporting, and documentation integrity at UT Health San Antonio.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Clinical Documentation Integrity, including knowledge of ICD-10-CM/PCS, DRG regulations, and medical terminology. Proficient in data analysis and effective communication with healthcare providers to enhance documentation practices.
Highest-signal resume keywords
ICD-10-CM/PCS KnowledgeClinical Documentation IntegrityData AnalysisRN, RHIT, RHIA, CDIP, or CCDS CertificationMedical Records Abstraction Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Documentation EvaluationMedical TerminologyHuman AnatomyPhysiologyPharmacologyDisease PathologyCoding Resources ProficiencyDocumentation ComplianceQuality Measure TrackingTechnical Troubleshooting
Soft Skills
Effective CommunicationMentoringTraining
Tools & Technologies
EPIC Software3M Encoder SoftwareOffice SoftwareCoding SoftwareBilling SoftwareAbstracting Systems
Certifications & Qualifications
RNRHITRHIACDIPCCDS
Industry Keywords
Clinical ValidationDRGHACHARMAcute Care Setting
About the role
Key responsibilities & impact- Evaluate documentation by medical staff and patient caregivers daily
- Ensure clinical information is accurate and complete for severity of illness, risk of mortality, DRG, and hospital outcomes reporting
- Initiate compliant verbal and written queries to clarify medical-record documentation
- Conduct follow-up reviews for completeness and consistency of the level of care
- Track and escalate HAC and HARM quality measures
- Assist with clinical validation reviews for denials and appeals
- Assist the CDI supervisor with provider education strategies
- Assist with mentoring or training new Clinical Documentation Integrity Specialists
- Analyze data and report quality issues to the CDI Supervisor
- Support organizational unbilled goals for Accounts Receivable with uncoded accounts
- Maintain strict confidentiality
- Perform other assigned duties
Requirements
What you’ll need- 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 to improve documentation practices
- Knowledge of ordinary business equipment in remote and office environments
- Ability to use office software, coding software, billing software, and abstracting systems
- Knowledge of coding resources and demonstrated proficiency in using them
- Ability to troubleshoot basic technical issues
- Ability to communicate effectively with providers and patient caregivers
- Required qualification: RN, RHIT, RHIA, CDIP, or CCDS
- HS Diploma or GED
- Clinical experience required
- Some experience in medical records abstraction and coding in an acute care setting required
- EPIC and 3M encoder software experience preferred
Benefits
Comp & perks- UT SELECT Medical insurance offered free for employees
- Discounted copays and coinsurance when using UT Health Physicians
- $50,000 group term life insurance
- $50,000 basic accidental death and dismemberment insurance
- Options to purchase additional employee and dependent coverage at group rates
- Three dental insurance plan options through Delta Dental
- Vision Care benefits with standard or enhanced vision options
- Disability Insurance
- Flexible spending accounts for dependent care or healthcare expenses
- Teacher Retirement System (TRS) or Optional Retirement Plan (ORP)
- Employer matching of employee contributions under TRS
- Voluntary retirement programs with five retirement plan providers
- Front-loaded Paid Time Off: 128 to 208 hours (16 to 26 days), based on years of service
- Extended Illness Bank: 8 hours accrued per month
- Paid Family Leave: up to 240 hours (6 weeks) after 6 months of consecutive employment
- 12 paid holidays annually
- Discounts on services, tickets, and gym membership