Title: Clinical Document Integrity Specialist - RN Location: Dallas, TX United States Location Type: Remote Job Number: 938850 Category: Nursing Job Description: WHY UT SOUTHWESTERN? With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the number 1 hospital in Dallas-Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you'll discover a culture of teamwork, professionalism, and a rewarding career! JOB SUMMARY The CDI Specialist facilitates appropriate clinical documentation reviews concurrently to ensure that the level of services and acuity of care are accurately reflected in the medical record to improve overall quality and completeness of clinical documentation. Communicates effectively with Physicians and the Healthcare Team. Initiates Provider queries as appropriate for documentation clarification and specificity. BENEFITS UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include: - PPO medical plan, available day one at no cost for full-time employee-only coverage - 100% coverage for preventive healthcare-no copay - Paid Time Off, available day one - Retirement Programs through the Teacher Retirement System of Texas (TRS) - Paid Parental Leave Benefit - Wellness programs - Tuition Reimbursement - Public Service Loan Forgiveness (PSLF) Qualified Employer - Learn more about these and other UTSW employee benefits! EXPERIENCE AND EDUCATION Required - Experience 3 years acute care Hospital nursing experience, preferably in critical care (i.e. ED, Trauma, Critical Care Units) and Two (2) years of experience working in a Clinical Documentation Integrity program or 5 years nursing experience in an acute care Hospital including Three (3) years in critical care (i.e. ED, Trauma, Critical Care Units - Licenses and Certifications (RN) REGISTERED NURSE and (CCDS) Cert Clinical Documentation obtained upon hire or within 6 months after eligibility requirements are met or (CDIP) CERT DOCUMNTATN IMPROVMNT PRAC obtained upon hire or within 6 months after eligibility requirements are met Preferred - Education Bachelor's Degree in nursing, BSN - Experience Experience working in a remote environment JOB DUTIES - Reviews patient records concurrently to ensure that the level of services and acuity of care are accurately reflected in the medical record to improve overall quality and completeness of clinical documentation. - Communicates effectively (face-to-face) with Physicians, the Healthcare Team, and Multidisciplinary Teams to ensure accurate and complete documentation of all relevant diagnoses, procedures and treatments. Provides education on clinical documentation opportunities to support acuity, quality, and coding. - Initiates Physician Queries for clarification and specificity as appropriate, following established query guidelines for compliant queries. Performs follow-ups to ensure clarification was documented prior to discharge. - Performs follow-up reviews and updates CDI/DRG worksheet to reflect changes in patient status, to verify the most appropriate Prin Dx and DRG and validate supporting documentation. - Works collaboratively with the Coding and Quality Teams to ensure the clinical documentation fills the 'gaps' between clinical and coding language. - Maintains an expert level of knowledge of CDI related practice and performance. - Provide backup for other CDI Specialists as needed. - Support the Quality Standards set by UTSW and the HIM Coding & CDI Department. - Other duties as assigned. SECURITY AND EEO STATEMENT Security This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information. EEO UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.

• Ensures accurate, complete, and compliant clinical documentation that appropriately reflects severity of illness, risk of mortality, and supports correct reimbursement. • Partners closely with providers, coding teams, and practice participants to drive documentation quality, regulatory compliance, and value-based care initiatives. • Develops and implements standard processes, job aids, and error prevention tools to strengthen clinical documentation integrity across participating practices. • Educates providers and office staff on best-practice clinical documentation standards to ensure accuracy, completeness, and compliance. • Conducts prospective and retrospective reviews and prepares analyses and reports to identify trends, gaps, and improvement opportunities. • Provides guidance and consultation to internal practice staff to improve coding proficiency and documentation accuracy. • Collaborates with population health and practice teams to support quality programs, value-based initiatives, and standardized data abstraction processes. • Advises practice staff on compliance with applicable federal, state, and local regulations related to Medicare coding and documentation guidelines.

• Lead CDI strategy, planning, development, implementation and maintenance of CDI program. • Manage projects associated with Mid Revenue Cycle and CDI initiatives. • Maintain processes aligned with regulatory and legal requirements. • Direct and manage the Clinical Documentation Integrity team. • Collaborate with Coding and HIM leadership to maximize outcomes. • Promote physician and provider education, engagement and collaboration.

Role Description The Clinical Denial Management Nurse is responsible for completing, tracking, and reporting clinical denials across all UF hospitals at an enterprise level. Reporting to the Enterprise Denial Nurse Manager, this role supports key revenue cycle functions including: - Clinical departments - Finance - Accounting - Compliance - Patient financial services - Revenue integrity - Managed care - Utilization review - Patient access Serves as a clinical expert in denial management, reviewing denied claims from a clinical perspective and developing effective appeal strategies. Ensures appropriate documentation and submission of appeals to maximize reimbursement and minimize organizational write-offs. Collaborates with cross-functional teams to identify denial trends, improve processes, and support enterprise-wide initiatives that enhance revenue cycle performance and compliance. Qualifications - Associate’s or Bachelor’s degree in Nursing required - Bachelor’s degree preferred - International Medical Graduate (IMG) with a Medical School Diploma may be considered in lieu of nursing degree - Active RN license required (if applicable based on education pathway) - Certified Clinical Documentation Specialist (CCDS), Certified Documentation Integrity Practitioner (CDIP), or equivalent CDI certification preferred Requirements - 5+ years of experience in Clinical Documentation Improvement (CDI), including leadership or lead-level responsibilities - Strong expertise in regulatory compliance, audit management, and clinical documentation standards - Proven ability to develop and implement training programs and process improvement initiatives - Demonstrated success leading cross-functional teams and collaborating with clinical and coding professionals - Experience monitoring documentation quality, analyzing trends, and reporting outcomes Company Description