Director of Inpatient Clinical Documentation

About Us

At Baylor Scott & White Health, we promote the well-being of all individuals, families, and communities. As the largest not-for-profit healthcare system in Texas, we empower 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. Offerings 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

The Director of Clinical Document Integrity (CDI) plans, develops, and implements clinical data validation and documentation for Baylor Scott and White Health (BSWH). This role directs clinical and technical aspects of provider data collection, aggregation, validation, auditing, presentation, and other CDI activities impacting the patient electronic health record (EHR). Responsibilities include developing and implementing CDI auditing procedures, designing clinical analytic solutions, and ensuring records comply with legal, accreditation, and regulatory requirements, including American College of Surgeons Standards and JCAHO.

A system Director translates and implements strategic plans and goals for their area, making final judgments on operational matters. This role recommends policies and organizational changes, plans and executes projects, and oversees department operations, including staffing, processes, budgets, and costs. Erroneous judgments at this level can negatively impact the area, business unit, or entire organization.

Responsibilities

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

Requirements

• 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.

Qualifications

• Education: Bachelor's degree or 4 years of work experience above the minimum qualification.
• Experience: 5+ years of relevant experience.
• Certification/License/Registration: Must have ONE of the following:
  • Certified Clinical Documentation Specialist (CCDS)
  • Certified Coding Specialist (CCS)
  • Certified Documentation Integrity Practitioner (CDIP)
  • Certified Professional Coder (CPC)
  • Certified Risk Adjustment Coder (CRC)
  • Registered Health Information Administrator (RHIA)
  • Registered Nurse (RN)

Belonging Statement

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