Clinical Documentation Specialist Ex
Odessa Regional Medical Center was founded in 1975 as Odessa Women’s and Children’s Hospital. Through the years, the hospital grew and evolved into a full-service healthcare facility and the name was changed to Odessa Regional Medical Center to reflect its larger campus and more comprehensive services. The hospital has 225 beds and has approximately 250 physicians on staff and has over 700 employees.
Today, ORMC offers a wide spectrum of healthcare services, including advanced diagnostic imaging technology, emergency care, innovative surgical procedures, maternity care, comprehensive cardiac services and general medical care.
About the position
The CDI Specialist is an integral part of the healthcare team and is responsible for ensuring that the patient record contains clinical documentation that is clear, concise, and clinically accurate to meet the goals of the CDI program. The CDI Specialist serves as part of the team responsible for improving the concurrent documentation practices in the hospital through ongoing education and works with physician clinical documentation, coding and reimbursement processes towards achieving quality and productivity goals.
- Minimum of five (5) years clinical experience or coding/reimbursement experience in acute care environment
- Current CDI certification preferred (must obtain within 18 months of employment through Association of Clinical Documentation Improvement
- Specialists/ACDIS OR American Health Information Management Association (AHIMA)
- Experience in practice of clinical documentation: nursing health information, case management, quality management or similar related field
- Knowledge of State charting requirements
- Knowledge of diagnoses/procedures in accordance with ICD-9 CM & CPT-4 coding principles
- Knowledge of all state, federal and private reimbursement systems
- Ability to work effectively with physicians, nurses and ancillary staff in a collaborative manner
- Ability to provide education to diverse group/teams within the healthcare environment.
- Proficient in computer skills with many softwares including, but not limited to, charting softwares, MS Office Suite, Lotus Notes.
- Ability to analyze large amounts of date, identify problems, patterns, trends/facilitate improvement actions needed
- Ability to multitask and take initiative to suggest process improvements
- Proven organization, analytical skills to identify patterns and trends.
- Ability to read and communicate effectively in English
Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.
This position is subject to the COVID-19 Vaccination Policy for Steward Health Care Workforce. Employees in this position will be required to provide adequate proof of vaccination for COVID-19 by an FDA-approved vaccine prior to starting work. Steward will consider requests for exemptions from this vaccine requirement on the basis of medical condition or sincerely held religious belief in accordance with applicable Federal laws.