Description

The Coding/CDI Audit-Educator primary responsibilities are to audit inpatient and/or outpatient University of Texas Southwestern Medical Center (UTSW) hospital medical records, for coding and/or clinical documentation accuracy.  Audit will be in accordance with current Coding/CDI, and UHDDS Guidelines, and in compliance with organizational, departmental, and regulatory requirements.  The Coding/CDI Audit/Educator is identified as the Coding/CDI subject matter expert based on education, training, and experience and as such will receive assignments in accordance with that level of expertise.  Additionally, the Coding/CDI Audit/Educator may be asked to mentor and proctor employees.    

ESSENTIAL FUNCTIONS
1.    Identify educational opportunities by auditing inpatient and/or outpatient accounts in compliance with the Official Coding/CDI, and UHDDS Guidelines and conventions.  And in compliance with organizational, departmental, and regulatory requirements

2.     CDI audits specific to PDx, POA, query compliance, risk adjustments variables, clinical substance, worksheet basics, etc. 

3.     Prepare and provide educational feedback to individuals and if relevant to the entire Coding and/or CDI Teams

4.      Research and prepare educational tutorials and submit to AHIMA/ACDIS for approval to provide Continuing Education Units (CEU’s) for the attendees.

5.      Accurately audits records for the most appropriate Principal Diagnosis, DRG, Reason for Visit, Procedures, and all reportable secondary diagnoses to accurately reflect the highest level of acuity as appropriate, i.e. CC/MCC's, POA status, Severity of Illness & Risk of Mortality, Vizient, Elixhauser and HCC risk variables.            

6.      Accurately audits abstracting for required data elements including, discharge disposition, discharge destination, procedure dates and physician(s), and other designated data.

7.      Identifies when a physician query is appropriate for further clarification.

8.      Recognizes when the documentation is missing or incomplete and recommends appropriate action  

9.      Support the Quality Standards set by UTSW.

10. Mentor/train on designated service lines as requested to ensure quality

11. Maintains an expert level of knowledge of Coding and/or CDI related guidelines and practices.

12. Other duties as assigned

Requirements

MINIMUM QUALIFICATIONS

Education/Experience

• Required three to five (3-5) years acute hospital-based CDI experience. An equivalent combination of education and experience may be considered
• Required RN
• Required Certified Clinical Documentation Specialist (CCDS)
• Preferred Bachelor's Degree
• Experience working in a remote environment preferred.