Job Summary

The Clinical Documentation Improvement (CDI) Specialist Lead provides onsite support of clinical documentation improvement activities to ensure accuracy and quality in patient records where coded diagnoses are an accurate reflection of the patient's clinical status and care. The CDI Specialist Lead serves a key role in maintaining the long-term CDI program success by providing intense oversight of the program at the facility. This role will be responsible for providing detailed assessments of the facility's/facilities' CDI program, Key Performance Indicators (KPIs), and implementing actions designed to facilitate the facility's achievement of leading practice CDI workflow, principles, and outcomes.

Essential Functions

• Assures accuracy of administrative (coded) data through Clinical Documentation Improvement (CDI) activities.

• Performs delivery of basic, intermediate and advanced level education for physicians, coders, Clinical Documentation Specialists (CDSs) and leadership relating to MS-DRGs and APR-DRGs, IPPS, ICD-10-CM/PCS, and the impact of documentation on severity of illness, risk of mortality, risk-adjusted quality metrics, value-based purchasing, and other CDI-related concepts.

• Possesses the ability to hire, teach and mentor Clinical Documentation Improvement professionals.

• Assists CDI staff with performance of CDI chart reviews as necessary utilizing CHS standard workflow, technology and query processes.

• Espouses compliant query practices as per Facility policy and AHIMA Query guidelines and ensures all queries issued are necessary, compliant, and non-leading.

• Collaborates with C-suite and Physician leaders to ensure program engagement and attainment of leading practice outcomes.

• Champions nationally-recognized Best Practice CDI workflow, principles and outcomes and effectively articulates recommendations for program improvement, and the rationale for the recommendations to facility and corporate CDI leadership.

• Leads the development and execution of physician education strategies resulting in improved clinical documentation and provides timely feedback to providers and physician leaders regarding clinical documentation opportunities for improvement.

• Ensures effective and compliant utilization of all Clinical Documentation Improvement and medical records/HIM software and tools.

• Confirms that all verbal, written, and electronic clarification activity is documented and accurately reported.

• Tracks and reports all CDI activities and ensures that CDI impact is reported accurately and appropriately. Creates and submits timely and accurate reports to the cdorporate CDI team and facility leadership.

• Utilizes only the facility-approved query forms, whether paper or electronic.

• Attends interdisciplinary rounds and facility or corporate meetings as assigned.

• Proactively develops a collaborative relationship with coding professionals and coding leadership to ensure accuracy of diagnostic and procedural data through completeness of supporting documentation.

• Actively and professionally collaborates with care managers, nursing, quality staff, ancillary staff and all members of the interdisciplinary care team.

• Adheres to official coding compliance regulations, corporate policies developed to ensure accurate billing, and industry best-practice clinical documentation principles.

• Keeps abreast of regulatory changes related to inpatient coding and documentation and quality metrics and communicates these changes to appropriate corporate and facility staff.

• Performs other duties as assigned.

• Complies with all policies and standards.

Qualifications

• Associate Degree in Nursing or comparable clinical field required

• Bachelor's Degree in Nursing or comparable clinical field preferred

• 4-6 years of acute care hospital nursing experience (e.g. medical/surgical unit, intensive care) required

• 2-4 years of prior experience in Clinical Documentation Improvement required

• 1-3 years of prior physician/provider education experience required

• 0-2 years of ICU/Critical Care experience preferred

• 0-2 years of experience in Utilization Management/Case Management, patient outcomes/quality management and/or inpatient coding preferred

• 0-2 years of prior coding and/or auditing experience preferred

Knowledge, Skills and Abilities

• Comprehensive knowledge of medical terminology, disease processes and clinical competency and exhibit broad-based clinical knowledge and understanding of pathology / physiology of disease processes, medications and diagnostic indicators.

• Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills.

• Strong critical thinking skills and ability to integrate knowledge is necessary. Prioritization and organizational skills required.

• Must exhibit the ability to educate members of the healthcare team about clinical documentation.

• Computer literacy and working knowledge of word processing software, spreadsheet software and reporting software. Familiarity with the operation of basic office equipment.

• Data quality and integrity skills.

• Broad knowledge of documentation requirements for accurate ICD-10 CM/PCS and MS/APR-DRG assignment and IPPS system

• Experience working with encoder software, clinical documentation improvement software and the electronic medical record.

• Excellent written and verbal communication skills. Excellent critical thinking skills.

• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.

• English language fluency is required for both verbal and written communication.

• Ability to work independently in a time-oriented environment.

• Ability to communicate effectively at a high level.

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license/certification required

• RHIA - Registered Health Information Administrator preferred or

• RHIT - Registered Health Information Technician preferred

• CDIP - Clinical Documentation Improvement Professional or CCDS- Certified Clinical Documentation Specialist preferred

• CCS-Certified Coding Specialist preferred or

• Certified Coder-AHIMA or AAPC or ICD-10 certification or trainer designation preferred

Equal Employment Opportunity

This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to http://www.chs.net/serving-communities/locations/ to obtain the main telephone number of the facility and ask for Human Resources.