Job Summary:

The Clinical Documentation Improvement Lead Specialist demonstrates excellent problem-solving, clinical knowledge, and coding knowledge requirements to support and improve the overall quality and completeness of clinical documentation in the patient medical record on a concurrent basis supporting and using a multi-disciplinary team process. The CDI Lead Specialist works collaboratively with the CDI team members, physicians and coding team members to ensure that clinical information in the medical record is present and accurate so that the appropriate clinical severity is captured for the level of service rendered to all patients. The CDI Lead Specialist supports the Departmental goal by assisting the department and organization in achieving clinical and operational excellence in relation to Clinical Documentation Improvement efforts.

Responsibilities:

• Conducts New CDI Specialist Onboarding & Education,
• Perform Staff risk adjustment audits, track and review findings and trends
• Assists management remotely with preparing provider education materials, gathering articles or other information for presentations and meetings.
• Initiates gathering topics, preparing and providing regular CDI education to team members based on trends, industry events and based on management needs
• Reviews medical records concurrent to the patient stay to determine opportunities as it relates to clinical documentation improvement, PSI, HACs, mortality, etc.
• Conducts and provide real-time audits of reviews, queries and reports and provide feedback on process, query opportunities and query compliance. Reviews data and trends to identify additional areas of opportunity.
• Conducts Validation and Special Project tasks to support the CDI Manager/Director and ensure appropriate data is entered, captured and reported in the CDI Software for the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
• Functions as a Super User with CDI Software and all other applications utilized in this position.
• Submits electronic queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population.
• Ensure queries are compliant, grammatically correct, concise and free of typographical errors.
• Provides appropriate follow up on all queries.
• Submit ideas to improve work flow and increase productivity of his/her team to the CDI Manager/Executive Director and perform any other duties as assigned.

Experience:

Required minimum

Experience:

Minimum of five years of healthcare experience required, strong medical/surgical background. Experience with Coding/DRG, billing, auditing and reimbursement is preferred. Clinician preferred with a CDIP/CCDS/CCS credential.Required minimum skills: High level of interpersonal and communication skills necessary to establish rapport with physicians and other healthcare providers. MS Office (Word, Excel, Outlook, and PowerPoint) knowledge is expected. Chart review experience required. Cerner Millennium Electronic Medical Record and 3M CDI Software experience is preferred. Regulatory background and DRG reimbursement knowledge preferred.

Education:

Bachelor's degree in healthcare or related field, required. Preferred:

• MD
• RHIT/RHIA: Registered Health Information Technician/Administrator
• RN: Current/active license as a registered nurse in the state of residence or current /active RN license with the ability to transfer license to state of residence within three months of start

Licenses / Certifications:

At least one of the following active certification/licenses required:

• CDIP: Clinical Documentation Improvement Practitioner
• CCDS: Certified Clinical Documentation Specialist
• CCS: Certified Coding Specialist, or equitable coding credential

Other:

Thorough knowledge of clinical documentation strategies and hospital-acquired conditions/present on admission and core measures; through knowledge of medical terminologies, procedures and applicable laws to collect and evaluate medical documentation; thorough knowledge of ICD-10, MS-DRGs, documentation compliance standards and coding principles and guidelines; good knowledge of healthcare delivery system, utilization review, case review and quality improvement practice and theory; skill in reviewing charts and utilizing electronic medical record and clinical documentation program; ability to communicate effectively and diplomatically within a multi-functional team which includes physicians, other members of the allied healthcare team and HIM coders; strong organizational, planning and observation skills; attention to detail; analytical-critical thinking and problem solving skills; excellent written and verbal communication; excellent computer skills and knowledge of software for database maintenance and electronic health record storage; ability to establish and maintain effective working relationships with all levels of medical, nursing, and non-professional staff; resourcefulness; flexibility; assertiveness; initiative; tact; creativity; thoroughness; sound professional judgment; physical condition commensurate with the demands of the position.

About Us:

NorthEast Provider Solutions Inc.

Benefits:

We offer a comprehensive compensation and benefits package that includes:

• Health Insurance
• Dental
• Vision
• Retirement Savings Plan
• Flexible Savings Account
• Paid Time Off
• Holidays
• Tuition Reimbursement