Clinical Documentation Specialist, Lead

The Lead Clinical Documentation Integrity (CDI) Specialist reports to the Director of Clinical Documentation, the Lead Clinical Documentation Specialist provides second level reviews for identified cases, provides complex chart reviews, and uses advanced CDI and coding knowledge to drive performance, identify opportunity, improve quality outcome measures and prevent denials. The Lead Clinical Documentation Specialist will have a role in providing education, including orientation and mentoring of new employees. The Lead may be asked to assist with cases on escalation and with denials/appeal letters. The Lead will facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. The Lead serves as a resource and mentor to all members of the health care team for coding and documentation guidelines.

• Position: Clinical Documentation Specialist, Lead
• Location: Edward Hospital (Naperville, IL)
• Full Time/Part Time: Full Time (40 hours)
• Hours: Monday-Friday, 8:00am-4:30pm
• Required Travel: travel to other Endeavor Health locations may be required for trainings and meetings

Medical Record Reviews/Day to Day Operations

• →Review medical records concurrently to ensure accuracy, completeness, and specificity of clinical documentation.
• →Identify and clarify missing, conflicting, or nonspecific physicians’ documentation through queries and follow up.
• →Collaborate with healthcare providers to ensure accurate and comprehensive documentation of patient diagnoses and treatments.
• →Monitors and assists with team case assignments to ensure accurate case coverage per organizational needs.
• →Identifies and provides feedback to the Director on optimization of workflow processes. Takes a case assignment as deemed necessary by the CDI Director during times of high census, PTO or short staffing.

Query Management and Compliance

• →Develop and implement effective queries to resolve documentation issues.
• →Ensure queries are clear, concise, and compliant with industry’s standards and regulatory requirements.
• →Track and follow up on outstanding queries to ensure timely responses.
• →Query format and questions meet AHIMA and ACIDS guideline.
• →Ensures adherence to professional standards, quality standards, licensure, and federal laws.

Quality

• →Ensure clinical documentation complies with all applicable regulations and standards, including those set by CMS, Joint Commission, and other governing bodies.
• →Performs complex chart reviews for advanced CDI topics and serves as a mentor to staff on such cases. May include DRG pre-billing opportunity reviews, or to identify/resolve denials risk.

Physician Collaboration and Education

• →Provide education to the physicians and other clinical staff on documentation best practice and importance of accurate clinical documentation.

Professional Development

• →Attend education programs, workshops, and one-one-one training to enhance continuous learning.
• →Participate in professional organization such as the Clinical Documentation Improvement Specialist (ACDIS) or the American Health Information Management. Actively engage in mentoring relationships to support less experienced colleagues and contribute to professional development within the team.

Other Duties as Assigned

• →May include but not limited to special projects related to Revenue Cycle, process improvement, task forces or Endeavor Health System workflows.

• →Education: Associates Degree in Nursing or Health Information Management, required. Bachelors Degree in Nursing, preferred.
• →Certification:
  • →RHIT or RHIA through AHIMA, preferred
  • →RN License through IDFPR, required
  • →Certified Clinical Documentation Specialist, preferred
  • →Certified Coding Specialist, preferred
• →Experience:
  • →3+ years recent inpatient clinical documentation specialist experience, required
  • →3+ years RN experience within an Acute Care Hospital (critical care preferred)
  • →3+ years HIM with CDI experience
• →Unique or Preferred Skills:
  • →Strong clinical knowledge and demonstrated commitment to maintaining relevancy in the clinical field.
  • →The communication skills to deliver presentations involving complex issues to a wide audience.
  • →Excellent analytical and communication skills.
  • →Ability to work independently and collaboratively in a team environment.