Role Description - Manages assignments and projects as assigned. - Participates in the daily operations and activities of the Clinical Documentation Improvement (CDI) program to continually enhance documentation. - Utilizes most current documentation tools available. - Regularly and effectively communicates with clinical staff. - Collaborates with coding in an effort to maintain coding and documentation quality and compliance. Ensures that coding process and guidelines meet State and Federal requirements and standards. - Works with the medical staff to continuously improve clinical documentation to facilitate accurate coding through the use of compliant physician queries, when appropriate. - Facilitates communication of various professionals to support organizational goals related to documentation integrity, compliance, quality and coding. - Assists in development and delivery of education for both clinical and non-clinical staff. - Meets performance standards by setting goals and objectives, prioritizing work, and using available resources efficiently and effectively. - Stays abreast of the latest developments, advancements, and trends in the field of documentation improvement and coding by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and maintaining certification or licensure. Integrates knowledge gained into current work practices. - Participates in the training of new employees as needed. - Ensures that work is completed accurately and according to schedule. Qualifications - Current registered nurse (RN) license with a Bachelor's Degree in Nursing plus 2 years of experience in acute care, health care administration or commensurate experience. - Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) credential must be obtained within one year of hire. - Experience with ICD-10-CM/PCS coding and DRG assignment. - Outstanding oral, written and interpersonal skills. - Demonstrated knowledge and clinical experience relevant to clinical and regulatory aspects of care and reimbursement. Preferred Qualifications - CCDS or CDIP upon hire plus 2 years of clinical documentation improvement experience.

Role Description This is a REMOTE opportunity. How you’ll contribute: - Facilitates improvement in overall quality, completeness, and accuracy of clinical documentation. - Conducts daily concurrent reviews of medical records to identify missing, vague and/or incomplete diagnoses and procedures. - Conducts timely follow up reviews of clinical documentation to ensure that issues discussed and issued queries have been answered by providers. - Queries physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines, clinical expertise and LifePoint Health query policy. - Participates in department and facility Quality and Performance initiatives. - Maintains education record and meets minimum corporate CEU requirements. - Maintains clean work station, follows all safety regulations, Code of Conduct and ethics, customer service, and attends hospital training and departmental staff meetings. Qualifications - Associate’s Degree Nursing (ADN): Required and validated by the presence of a current RN license; Bachelor’s Degree Nursing (BSN): Preferred - Registered Nurse; One of the following is Preferred - Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist - Physician-base (CCS-P), Certified Coding Specialist (CCS) - Three years of clinical work experience Required Requirements - Minimal completion of Level One on the Clinical Ladder Program annually for Full-time nurses. If not completed, employee forfeits the annual evaluation pay increase and possible termination. Benefits - Comprehensive Benefits: Multiple levels of medical, dental and vision coverage with medical plans starting at just $10 per pay period tailored benefit options for part-time and PRN employees, and more. - Financial Protection & PTO: Life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave and paid time off. - Financial & Career Growth: Higher education and certification tuition assistance, loan assistance and 401(k) retirement package and company match. - Employee Well-being: Mental, physical, and financial wellness programs (free gym memberships, virtual care appointments, mental health services and discount programs). - Professional Development: Ongoing learning and career advancement opportunities.

• Focus on drafting patient-facing clinical documents in lay language : • Drafting and revising (as needed): Lay summaries of Clinical Study Reports (CSR lay summaries), Protocol synopsis in lay language (Plain Language Protocol Synopsis) • Coordination of : authoring activities, document planning, review cycles with stakeholders • Maintaining scientific accuracy • Meeting EU CTR / CTIS plain-language expectations • Coordinating multi-stakeholder reviews within timelines • Ensuring robust quality control and version management • Content planning and outline proposal • Drafting from : CSR / protocol, supporting materials • Incorporation of review comments • Version management • Final document preparation • Contribution to : terminology consistency, glossary, readability

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.