Job Description

Position Summary / Career Interest:

The Clinical Documentation Integrity Specialist (CDS) Lead will audit the Clinical Documentation Specialists reviews of inpatient medical records for completeness, accuracy, and query compliance. The CDS Lead will gather and analyze data from various sources to share and strategize improvement with the manager. The CDS Lead will use date to evaluate and educate CDSs, coders, attending physicians, residents, fellows, and Advanced Practice Providers (APP) to suggest additional and/or more specific documentation in support of the Clinical Documentation Improvement (CDI) program. The CDS Lead will work closely with the CDS Manager and Coding Leadership to assure documentation of discharge diagnosis(es) and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care.

Responsibilities and Essential Job Functions

• Work independently to problem solve, gain knowledge, and complete assignments and projects in the interest of the CDI department.
• Complete special projects as assigned by the CDI department manager, in an efficient and effective manner, and provide pertinent and timely results to the CDI department manager for review.
• Monitor, analyze, and track the quality and performance of the CDI program through gathering and interpretation of reports and data, and share findings with the CDI department manager and identified staff.
• Educates Physicians and Staff regarding severity of illness, risk of mortality, and other risk-adjustment methodologies documentation.
• Collaborates with Physicians, Advanced Practice Providers, CDI Staff, and HIM Coders as well as works directly with individuals and departments where documentation improvement opportunities exist.
• Coordinates data and documentation compliance and collaborates on all aspects of the program to improve clinical documentation.
• Administers training sessions to new Health System Staff, Attending Staff, Nursing and Ancillary personnel as assigned by the CDS department manager.
• Educates, trains, and precepts new members of the CDI team to the Health System, Program Goals, Program Processes and deliverable to the health system.
• Identifies learning needs of members of the CDI Team and provides education and resources to improve knowledge and skills.
• Identifies opportunities to improve department processes and quality metrics and reports them to the CDI department manager.
• Collaborates with the CDI department manager to create workflows and guidelines for the team's work.
• Maintains current knowledge of CDI and Inpatient Coding Industry Trends and changes (e.g. IPPS updates, Coding Clinic updates).
• Performs initial concurrent CDI chart reviews, identifying opportunities for query, communicates queries using the established Query Policy and CDI department process.
• The CDS Lead will assist with 3rd Party Payor Denials and other DRG denial projects.
• The CDS Lead will perform other duties and special projects as directed by the CDI department manager.
• Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
• These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required.

Required Education and Experience

• Bachelor Degree Nursing from an accredited college or university.
• 3 or more years of experience in an acute care setting.
• 18 months of experience in Clinical Documentation Improvement/Integrity (CDI).
• 5 or more years of coding experience in inpatient and/or outpatient ICD-10 CM/PCS.
• 5 or more years of experience in Clinical Documentation Improvement/Integrity (CDI).

Required Licensure and Certification

• Licensed Registered Nurse (LRN) - Single State - State Board of Nursing Must have a current RN license in Kansas. Will also accept foreign medical graduate (MD) with CDI certification of CCDS and/or CDIP in lieu of Kansas RN license.
• Kansas State Board of Nursing, or CCDS and/or CDIP certification for foreign medical graduates with MD.
• Will also accept RHIT, RHIA, or CCS with CDI certification of CCDS and/or CDIP in lieu of Kansas RN license.

Preferred Licensure and Certification

• CDI certification of CCDS and/or CDIP.

We are an equal employment opportunity employer without regard to a person’s race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, ancestry, age (40 or older), disability, veteran status or genetic information.

Job Tags

Similar Jobs