Employment Type : Full-Time
Summary: Independent review and Manages all CDI work ques to Identifies technical issues Performs Advanced Expert Demonstrates Excellent WORK INDEPENDENT
The Lead Clinical Documentation Integrity Specialist
(CDI) will directly report to the Manager of Clinical Documentation. Under
general supervision and within Lifespan policies and procedures is responsible
for concurrent review of medical record documentation to assist with evaluating
and improving the quality of clinical documentation of services to adequately
reflect severity of illness expected risk of mortality and complexity of care
of the patient.
The Lead Clinical Documentation Integrity Specialist
is responsible for the orientation of new staff identification of process
improvements development of education material for CDI coding staff and the
provider community. The Lead CDI Specialist will have an integral role in the
updating and implementation of the department?s IS systems. In addition the Lead CDI Specialist will be
responsible for independent response to payer audits auditing of providers as
well as departmental auditing.
Responsibilities:
Demonstrates expert knowledge of clinical
documentation issues as they relate to proper assignment of ICD 10 CM and PCS codes
and MS-DRG/APR DRG assignment.
Takes lead role in
on-boarding and precepting new staff. Identifies opportunities for education
for less experienced staff and the department.
response to commercial and governmental audits.
Oversees staff education on review
of mortality and HAC/PSI reviews. Has knowledge of up to date risk adjustment diagnoses.
Identifies documentation and coding improvements to improve capture of risk
adjustment diagnoses and develops education for CDI and coding staff.
Audits individual providers
or departments and develops and presents education to improve the quality of
documentation.
Demonstrates expert technical
ability with 3M 360 LifeChart as well as other programs.
ensure efficient review of cases.
and works independently with the IS team to resolve.
Assist with testing for
system upgrades and implementation of new systems.
Develops and revises internal
policies and procedures.
Performs internal department
auditing. Identifies opportunities and develops the plan for improvement.
Keeps abreast of new coding
guidelines coding clinics and clinical developments that affect documentation
and coding. Develops education for CDI
and coding staff.
Identifies develops and
presents information that will improve documentation and accurate coding to the
CDI coding staff and provider community.
In the absence of the manager
and or the director is able to manage the staff?s daily assignments.
other duties as assigned.
Other information:
BASIC KNOWLEDGE & EDUCATION:
Registered
Nurse with current licensure to practice in State of Rhode Island. Bachelor?s Degree required Master?s Degree
preferred.
Demonstrates
expert knowledge of clinical care current standards and treatment of assigned
patient population.
understanding of coding guidelines as they pertain to the specificity of
clinical documentation.
knowledge of coding and coding guidelines.
ability to prioritize work in order to be efficient and productive.
verbal and written communication skills.
Good
interpersonal skills with ability to identify and effectively resolve issues.
EXPERIENCE:
Six
years of experience as a Clinical Documentation Specialist required. Holds a
certification in clinical documentation integrity.
Expert
knowledge of 3M 360 and Lifechart.
Active
engagement in educational offerings through department as well as on own.
ENVIRONMENT AND PHYSICAL REQUIREMENTS:
Work is performed in general office environment and
patient care areas. Incumbent is required to have the ability to: read and
comprehend medical record documentation lift a minimum of 25 pounds bend
stoop and stretch sit for prolonged
periods using a computer mouse and reading from a computer monitor required.
ACTION:
Incumbent
functions independently within the department?s policies and procedures. Refers specific complex issues to supervisor
when clarification of policies and procedures is required.
SUPERVISORY RESPONSIBILITY:
None.
General oversight of Clinical Documentation Specialists and Sr Clinical
Documentation Specialists.
Lifespan is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status. Lifespan is a VEVRAA Federal Contractor.
Location: Corporate Headquarters USA:RI:Providence
Work Type: Full Time
Shift: Shift 1
Union: Non-Union