Where compassion meets innovation and technology and our employees are family.

GENERAL PURPOSE OF JOB:
The Lead Clinical Documentation Department Improvement Specialist is a certified coder with a high level of clinical proficiency necessary for leadership of the Clinical Documentation team of licensed nurses and certified coders. Oversees the review processes of complex pediatric patients in accordance with all current payer initiatives and development in acute and chronic disease states; understands a wide range of specialized disciplines, including education in anatomy and physiology, pathophysiology, and pharmacology; knowledge of official medical coding guidelines, CMS, and private payer regulations related to the Inpatient Prospective Payment System; an ability to analyze and interpret medical record documentation and formulate appropriate physician queries; and an ability to benchmark and assist in analyzing clinical documentation program performance.
 

Exhibits a sufficient knowledge of clinical documentation, coding reporting requirements, APR-DRG assignment, and clinical conditions or procedures impacting severity of illness, risk of mortality, and/or data quality.
 

Facilitates complete and accurate documentation and coding of inpatient medical records on a concurrent and retrospective basis by serving as a resource for HIM coders and physicians regarding proper documentation practices
and the link to ICD-10 codes and APR-DRG assignments.
 

Collaborates with interdisciplinary teams including, but not limited to, physicians, nurse practitioners, PA's, Quality, Case Management, Risk Management, Health Information Management/Coding, Decision Support, product vendors,
and other members of the health care team to provide data and solution development processes.
 

The Lead Clinical Documentation Improvement Specialist is involved in the direction and education of all phases of the Clinical Documentation process and will work in a collegial manner with physicians and support staff. Requires
knowledge and leadership of the day-to-day processes of the Clinical Documentation team including workflow and training needs to meet the expected requirements. Assists management with providing ongoing Clinical
Documentation education for current and new staff, including new Clinical Documentation Specialists, physicians, nurses and allied health professionals, and with tracking and trending program performance.
 

Maintains professional development by participating in workshops, conferences, and/or in-services keeping appropriate records of participation.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or hospital administration as required.

• Completes initial reviews/concurrent coding within 1 -2 working days in order to promptly identify potential documentation improvement opportunities.
• Conducts follow-up reviews/concurrent coding of patients every 2-3 working days to support and assign a working or final APR- DRG. Queries physicians regarding missing, unclear, or conflicting health record documentation.
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
• Collaborates with CDI Physician Champion, case managers, nursing staff,
  and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.
• Participates in the analysis and trending of statistical data for specified patient populations to identify documentation improvement opportunities.
• Assists with preparation and presentation of clinical documentation monitoring/trending reports for review.
• Partners with the coding professionals when necessary to
  ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to assign 1CD-10-CM/PCS diagnosis and procedure codes to determine an accurate working and final APR-DRG, severity of illness, and/or risk of mortality.
• Ensure accuracy and optimization of quality initiatives such as Potentially Preventable Events, ICD-10, Data Governance, and future initiatives by performing concurrent/retrospective coding and CDI reviews and facilitating workflow.
• Reviews all mortality and PPE accts notified by CQA for coding documentation opportunities and communicates with QA dept as necessary.
• Assists other CDI Specialists with daily software, coding, workflow, and CDI questions as able.
• Communicates with CDI Champion as needed to discuss no response queries or obtain objective clinical perspective.
• Assist with retrospective coding review needed for statistical validation for external reporting entities such as STS, THCIC, and CHA.
• Ensure accuracy and optimization of quality initiatives such as Potentially Preventable Events, ICD-10, Data Governance, and future initiatives by performing reviews and facilitating workflow.
• Demonstrates a consistent level of performance and strives to maintain a steady level of productivity in all duties assigned.
• Assist HIM management with software implementation/testing/updates/support.
• Maintains utmost level of confidentiality at all times.
• Adheres to hospital policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to compliance and integrity guidelines.
• A teamwork approach, organization, problem-solving skills and flexibility are required.
• Demonstrates a thorough knowledge of computer applications and the ability to do research.
• Excellent interpersonal and communication skills required, professionalism is essential.
• Proficiency in the use of Microsoft applications (e.g. Word, Excel, PowerPoint), Epic, and 3M 360.

EDUCATION AND/OR EXPERIENCE:
RHIA, RHIT, or CCS with a minimum of three years hospital-based inpatient coding experience, or are clinical candidates credentialed as RN, LVN or BSN with a strong clinical background and a minimum of three years clinical experience in Pediatrics, Med-Surg, ICU, or Surgery.
 

CERTIFICATES, LICENSES, REGISTRATIONS.

• CCS coding certification required or CCS eligible- to be achieved within 1 year of employment.
• CDIP, or CCDS, eligible- to be achieved within 1 year of employment.
• RN, LVN or BSN preferred.