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Clinical Documentation Lead (Technology)

VIRTUAL-GA • Atlanta, Georgia • Day Shift • Full Time • JR-5137

Job Summary:

The Clinical Documentation Integrity Lead demonstrates excellent clinical proficiency and critical thinking skills necessary to support and improve the overall quality and completeness of clinical documentation in the patient medical record. Assists the CDI leadership team in creating a support structure within the department for achieving clinical and operational excellence in relation to Clinical Documentation Integrity efforts. Collaborates with clinical and non-clinical team members at Wellstar facilities to achieve department goals in relation to Clinical Documentation Integrity efforts, as well as interdisciplinary teams including, but not limited to, physicians, nurse practitioners, PA's, and the department representatives for Revenue, Coding, Care Coordination and Health Information Management. Plays key role in determining metric measurements that are meaningful to the CDI department and will assist in analyzing, tracking, trending, and reporting CDI and/or organizational data and metrics at both system and individual facility-level. Presents the results of studies, trends, and activities as necessary to demonstrate solution performance and improvement in clinical documentation. Assumes responsibility for professional development through participation in workshops, conferences and/or in-services and maintains appropriate records of participation. Works collaboratively with team members to provide data and solution development processes. Demonstrates ability to assist in process and workflow improvements, system technology implementations and project management. Provides ongoing Clinical Documentation Integrity program education for new team members, including but not limited to, Clinical Documentation Specialists, physicians, nurses and allied health professionals. This is a Leadership Job

Core Responsibilities and Essential Functions:

Specializes in 1) CDI Specialist Onboarding Education, 2) In collaboration with physician partners, ensures physician education, or 3) Performs Audits. Assists management remotely with preparing provider education materials, gathering articles or other information for presentations and meetings. Performs staff, PSI, HAC, HAI, mortality, etc. reviews remotely as assigned by management. a)Initiates gathering topics, preparing and providing regular CDI education to team members based on trends, industry events and based on management needs b)Conducts new specialist onboarding and education c)Reviews medical records concurrent to the patient stay to determine opportunities as it relates to clinical documentation improvement, PSI, HACs, mortality, etc. d)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. e)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. f)Functions as a Super User with CDI Software and all other applications utilized in this position. g)Assists with payroll as it relates to timekeeping duties as assigned by management Reviews clinical documentation remotely during patient admissions to determine opportunities to improve physician documentation and communicates identified opportunities to the physician. a)Reviews medical records to determine opportunities to query physicians regarding clinical documentation b)Conducts follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart. c)Performs hospital-wide medical record reviews facilitating improvement in the quality, completeness and accuracy of medical record documentation to ensure coding compliance, accurate reporting, and improved patient outcomes. d)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. e)Ensure queries are compliant, grammatically correct, concise and free of typographical errors. f)Provides appropriate follow up on all queries. g)Notifies CDI Manager immediately when queries are not answered. Provides all data necessary for onsite Regional CDI Manager to assist. h)Reconciles all appropriate records daily in CDI software tool to ensure appropriate reporting is generated. i)Maintains required daily/weekly/monthly metrics. Meets productivity standards. j)Participates in required onsite meetings, conference calls and Skype presentations. k)Adheres to departmental Policies and Procedures. l)Participates in assuring hospital compliance with Federal and State regulatory requirements. m)Submit ideas to improve work flow and increase productivity of his/her team to the CDI Leadership team and perform any other duties as assigned. Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement. a)Participates in assuring hospital compliance with Federal and State regulatory requirements. b)Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process.

Job Titles Reporting to this Job:


Builds a culture of trust and engagement as reflected in the Great Place to Work Trust Index Survey at a direct report, workgroup and hospital/entity level. Holds leaders accountable for behaviors that create trust and engagement. Performs all duties and responsibilities of this position in a manner that reflects the values of WellStar. Maintains and strengthens relationships with physicians and assures their involvement in developing systems to assure the growth of the service and the cost effective delivery of quality patient care in a manner that fosters patient and employee satisfaction.

Results Oriented Leadership:

Sets challenging and productive goals for team. Holds team accountable for actions while providing leadership and motivation. Provides resources and support, Uses checkpoints and data to track progress, setting up system and processes to measure results.

Collaboration and Partnership:

Required Minimum Education:

Associate's Degree in nursing Required or Bachelor's Degree in a healthcare-related program Required or Doctorate Completed degree from an accredited medical school Required

Required Minimum License(s) and Certification(s):

Cert Clin Document Specialist 1.00 Required Cert Document Improvement Prac 1.00 Required Reg Nurse (Single State) 2.00 Required RN - Multi-state Compact 2.00 Required Cert Coding Spec 2.00 Required Cert Prof Coder 2.00 Required Reg Health Information Admin 2.00 Required Reg Health Information Tech 2.00 Required

Additional Licenses and Certifications:

It is expected that all RN’s are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association Upon Hire Required

Required Minimum Experience:

Minimum 2 years working in an acute care setting as a Clinical Documentation Specialist (CDS) Required and Minimum 5 years healthcare experience Required and Prior experience of working as a CDI/Coding auditor is preferred Preferred and Prior experience of working in inpatient case management or utilization review is preferred Preferred and

Required Minimum Skills:

Strong understanding of disease processes, clinical indications and treatments; and provider documentation requirements to reflect severity of illness, risk of mortality and support the diagnosis/procedures performed for accurate clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payors Familiarity with encoder and current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS and APR) Epic and 3M360 experience is preferred Expert knowledge/experience in managing all aspects of Clinical Documentation Integrity, including CDI productivity, quality, education and training, compliance auditing, data analysis and trending, report management, performance improvement initiatives Chart review experience required. Excellent communication skills, employing tact and effectiveness Demonstrate effective communication skills and collaborates with medical staff, clinical departments, and key facility leadership team members Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives Excellent problem-solving skills, with the ability to recommend and implement practical and efficient solutions Must have proficient computer skills in Microsoft Apps, such as Word, Excel and PowerPoint, as well as CDI technology tools required for the job functions Must be comfortable with doing data analysis, and preparing and maintaining records and written reports Drives optimal use of the CDI technology tool and reporting capabilities Excellent time management, training and peer development skills

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