Director of Inpatient Clinical Documentation

About Us

Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well.

Our Core Values are:

• We serve faithfully by doing what's right with a joyful heart.
• We never settle by constantly striving for better.
• We are in it together by supporting one another and those we serve.
• We make an impact by taking initiative and delivering exceptional experience.

Benefits

Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include:

• Immediate eligibility for health and welfare benefits
• 401(k) savings plan with dollar-for-dollar match up to 5%
• Tuition Reimbursement
• PTO accrual beginning Day 1

Note: Benefits may vary based upon position type and/or level.

Job Summary

Dir Clinical Document Integrity (CDI) plans, develops, and implements clinical data validation and documentation for Baylor Scott and White Health (BSWH). Directs clinical and technical aspects of provider data collection, aggregation, validation, auditing, presentation, and other CDI activities impacting the patient electronic health record (EHR). Develops and implements CDI auditing procedures to ensure accurate and standardized clinical documentation. Designs and deploys clinical analytic solutions to drive clinical improvement for patient care in BSWH hospitals, clinics, and ambulatory care facilities. Develops and implements CDI policies, processes, protocols, workflows, and methodologies for organizing clinical provider data. Identifies and resolves data discrepancies and develops data quality improvement plans using standardized processes. Ensures records comply with all legal, accreditation, standards, and regulatory requirements, including the American College of Surgeons Standards and JCAHO. May develop and deliver CDI education or training on application updates, process workflows, and data trends. Coordinates with medical, clinical, informatics, information systems, and other revenue cycle departments to ensure patient documents and information are accurate.

A system Director translates and implements strategic plans and goals for their area. Makes final judgments on operational matters and ensures goals are met. Recommends policies and organizational changes for the area. Plans and executes projects and initiatives that meet annual goals. Erroneous judgments at this level can negatively impact the area, business unit, and possibly the entire organization. Plans and directs department operations, responsible for staffing, processes, budgets, and costs. Guides and advises subordinates to meet schedules, resolve technical problems, and monitor performance. Oversees a larger, more complex organization or area than a manager. Often has one or more managers or supervisors reporting to them.

Essential Functions of the Role

• Directs the clinical document integrity (CDI) function for assigned area of responsibility for BSWH.
• Recommends and implements strategic and operational plans and priorities for CDI programs aligned to BSWH overall business goals.
• Develops and implements inpatient and outpatient policies, procedures, and processes for CDI. This is based on accurate capturing, reporting, and examination of identified metrics.
• Utilizes data analytics to optimize staffing, educational focus and to identify potential areas requiring additional attention.
• Directs CDI initiatives and program activities, including roadmaps, timelines, steering and subcommittee minutes, training tools.
• Manages the CDI continuous performance improvement in targeted areas.
• Monitors, reviews, and revises data architecture and CDI governance controls.
• Manages gap analysis of performance data and operational trends. Reports findings to all organizational levels. Provides constructive feedback and suggestions for improvement.
• Creates, develops, and replicates reports while maintaining reporting consistency, validating multiple data elements, metrics, and reporting structure.
• Manages the ongoing assessment and optimization of workflows for technology or operational needs.

Key Success Factors

• Bachelor’s degree in a clinical field, healthcare information, or related field preferred.
• 5+ years of experience in clinical document management, clinical applications management, or related area.
• 1+ years of experience in a leadership role.
• Experience in healthcare technology implementation and project management.
• Ability to develop and communicate clinical workflows and system design requirements.
• Understanding of medical information usage and clinical software and hardware tools.
• Excellent written, verbal, presentation, and technical writing skills.
• Active license or certification preferred in one of the following: Registered Nurse (RN), Registered Health Information Administrator (RHIA), Certified Clinical Documentation Specialist (CCDS), Certified Coding Specialist (CCS), Certified Documentation Integrity Practitioner (CDIP), Certified Professional Coder (CPC), or Certified Risk Adjustment Coder (CRC).

Belonging Statement

We believe that all people should feel welcomed, valued and supported.

QUALIFICATIONS

• EDUCATION - Bachelor's or 4 years of work experience above the minimum qualification
• EXPERIENCE - 5 Years of Experience
• CERTIFICATION/LICENSE/REGISTRATION -

Cert Cln Documentation Spec (CCDOCSP), Cert Coding Specialist (CCS), Cert Doc Improv Practitioner (CDIP), Cert Professional Coder (CPC), Cert Risk Adjustment Coder (CRC), Reg Health Info Administrator (RHIA), Registered Nurse (RN): Must have ONE of the following:

Cert Cln Documentation Spec - CCDOCSP
Cert Coding Specialist - CCS
Cert Doc Improv Practitioner - CDIP
Cert Professional Coder - CPC
Cert Risk Adjustment Coder - CRC
Reg Nurse - RN
Reg Health Info Admin - RHIA.