Department/Unit:

Clinical Documentation Improvement

Work Shift:

Day (United States of America)

Salary Range:

$78,773.63 - $122,099.12

This supervisory position will lead and oversee a Clinical Documentation Integrity educational program for CDI specialists and providers, in both inpatient and outpatient setting, including:
1. Working with program leadership to plan, develop, and implement clinical documentation education programs for CDI specialists and providers.
2. Analyzing data to ascertain where effective education is needed for both providers and staff.
3. Fostering an environment of continuous learning for CDI specialists and providers.
4. Collaborating extensively with providers, and medical coding staff to improve quality and completeness of documentation of care provided and coded.
5. Educating members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management.
6. Conducting individual and large group educational sessions for all CDI Specialists, Coders, Quality management nurses and/or providers.
7. Performing query and chart audits to assure query compliance.
8. Working closely with the CDI Specialists to identify areas of non-specific documentation.
9. Developing tools assist CDI specialists bridge existing and potential documentation gaps.
10. Facilitating the ongoing relevance of department specific orientation content, educational materials, and training programs/resources.
11. Educating providers on the subject of accurate and ethical E/M coding and documentation.
12. Submitting appeals for clinical validation in compliance with ICD 10 coding guidelines and review of recent literature.
13. Works closely with Quality management and Coding on accurate capture of PSIs and HACs and on reviewing mortalities.

CDI Auditor

Job Description Summary

This supervisory position will lead and oversee a Clinical Documentation Integrity educational program for CDI specialists and providers, in both inpatient and outpatient setting, including:
1.   Working with program leadership to plan, develop, and implement clinical documentation education programs for CDI specialists and providers.
2.   Analyzing data to ascertain where effective education is needed for both providers and staff.
3.   Fostering an environment of continuous learning for CDI specialists and providers.
4.   Collaborating extensively with providers, and medical coding staff to improve quality and completeness of documentation of care provided and coded.
5.   Educating members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management.
6.   Conducting individual and large group educational sessions for all CDI Specialists, Coders, Quality management nurses and/or providers.
7.   Performing query and chart audits to assure query compliance.
8.   Working closely with the CDI Specialists to identify areas of non-specific documentation.
9.   Developing tools assist CDI specialists bridge existing and potential documentation gaps.
10.   Facilitating the ongoing relevance of department specific orientation content, educational materials, and training programs/resources.
11.   Educating providers on the subject of accurate and ethical E/M coding and documentation.
12.   Submitting appeals for clinical validation in compliance with ICD 10 coding guidelines and review of recent literature.

13. Works closely with Quality Management and Coding on accurate capture of PSIs and HACs and on mortality reviews

Job Description

Performs query and chart audits to assure query compliance and to identify areas of non-specific documentation, followed by CDI and provider educational feedback
Builds strong relationships with key stakeholders across multiple departments within AMHS including but not limited to Medical and Surgical Departments, HIM, Quality Management, Revenue Cycle, Dietary Services and Case Management to assure that the CDI strategic goals are aligned with the hospital-wide long-term planning
Collaborates with the CDI Director and CDI Manager in continuously developing AHIMA approved curriculum
Works with other healthcare professionals across the healthcare system to identify opportunities for process improvement and quality improvement
Prepares and presents AHIMA approved educational sessions for Inpatient CDI specialists and Coders
Develops recurring educational sessions for physicians to improve their understanding of E&M coding guidelines, documentation requirements to support accurate inpatient and outpatient E&M coding, and documentation tools.
Develops and provides group educational sessions or one-on one sessions, if necessary, to teach physicians how applying E/M guidelines ensures compliance, optimizes reimbursement, and streamlines the documentation process.
Empowers physicians to take charge of their E/M coding and documentation by customizing presentations and offering specific recommendations to improve compliance
Maintains own education leadership skills through participation in continuing education and development activities
Leads a CDI auditing program and in doing so, unifies CDI quality standards across the four campuses within the Albany Med Health System
Oversees the CDI/Coder DRG mismatch review process in support of AMHS’s ethical coding practice
Prepares and presents specialty specific educational material utilizing real life clinical examples to show physicians and other qualified health care professionals how to apply the E/M guidelines in daily practice

Minimum Qualifications

RN with bachelor's degree in nursing or MD, DO, or foreign educated medical graduate with advanced clinical practice experience - ECFMG certificate is a plus
Valid CDI Certification such as CDIP or CCDS required
Coding certification to be obtained within the first two years of employment
RN license preferred
Advanced clinical experience with extensive knowledge of complex disease processes and broad clinical practice experience in the inpatient and outpatient settings required.
At least 5 years adult acute care practice experience with teaching/mentoring
At least 3-5 years of CDI experience
5+ years of experience in teaching or mentoring position
Must be able to function independently, interpret information, communicate with medical and clinical staff and both internal and external to the institution
Able to provide oral presentations both in person and virtually
Must be motivated, organized with excellent verbal, written communication skills, and conversant with adult professional learners.
Ability to work independently and as a member of a team utilizing critical thinking skills.
Demonstrates competence in data analysis and data interpretation.
Has extensive knowledge of ICD-10 codes and coding guidelines.
Ability to prioritize workflow and manage various initiatives.
Demonstrated quality improvement knowledge/skills regarding workflow and productivity processes.
Strong speaking and writing skills required.
Excellent presentation skills required.
Able to produce reports in Microsoft Office components, Word, Power Point, Excel, and Access data bases
Demonstrated effective facilitation skills.
Good listening skills.
Strong interpersonal communication skills with the ability to relate to all levels of education and organization positions.
Collaborates across AMHS CDI departments to drive unified goals and results.
Demonstrates success in teaching CDI specialists and healthcare providers across the Health System quality documentation standards.
Has extensive knowledge and ability to teach E/M coding guidelines.

Remote work

This role is eligible for consideration of remote work. On site presence will be required on an as needed basis.

Thank you for your interest in Albany Medical Center!

Albany Medical is an equal opportunity employer.

This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:

Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.