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Clinical Documentation Integrity Specialist Lead

You must reside in one of these states to be eligible for this position:

Arkansas    California    Kentucky
Massachusetts Nevada    New Mexico
Oregon     Utah     Tennessee
Texas     Wyoming

Employment Type: Full Time
Location: Remote
Reports To: Director, Clinical Documentation Integrity
Department: Clinical Operations

Job Summary:

The Clinical Documentation Integrity Specialist (CDIS) Lead is an advanced level position for the experienced and proficient CDI Specialist consistently meeting or exceeding all criteria for CDIS advanced performance, with an additional emphasis on management responsibilities and expanded scope of oversight. The CDIS Lead provides support to CDI leadership within a defined scope of facilities and CDI team. The CDIS Lead serves as a liaison between senior leadership, medical staff, nursing, coding, case management and quality departments. Excellent communication skills, interpersonal skills, and the ability to identify, problem solve, and independently direct self and others is a key component of the CDIS Lead role. The role encompasses leadership and management responsibilities with a focus on career growth and development.

Key Responsibilities:

May be assigned special projects related to CDI processes, quality, data analysis, or HIM/CDI performance

Assumes responsibility for daily workflow process and adjustments for the CDI team

May present CDI performance metrics at facility meetings

May present CDI education as needed

Will assume operational oversight in the absence of the CDI Director

Supports CDI team through multidisciplinary approach in support of program goals

Facilitates collaborative efforts between CDI, HIM and Medical Staff providers

Facilitates collaborative efforts between CDI and clinical teams such as Quality and Case Management

Effectively utilizes leadership abilities and critical thinking skills to identify opportunities for team process and engagement optimization

Maintains professional competency in documentation and coding practices by keeping up to date with new coding guidelines, policies/procedures, federal and state reimbursement.

All tasks must be performed in accordance with the established CDI daily workflows with adherence to Inpatient CDI Handbook protocols.

Maintains confidentiality within the leadership team concerning all responsibilities described herein

Consistently communicates both verbally and in writing with CDI Director, reporting potential and/or actual problems identified

May be requested to perform other related tasks, record reviews or responsibilities as assigned.

Performs all the above functions with minimal supervision and optimal accuracy and efficiency.

Promotes a positive, engaging, and professional culture supportive of CDI Program goals and standards.

Actively supports CDI program initiatives implemented by CDI leadership

Required Skills & Qualifications:

Must possess strong organizational, communication, time management and clinical foundation skills.

Must demonstrate proficiency in EMR software, CDI applications (after education and orientation) and Microsoft applications.

Demonstrates ability to multi-task and work efficiently and effectively between software platforms.

Demonstrates the ability to communicate effectively in a fast-paced environment with multidisciplinary teams consisting of physicians, nurses, coders, administration and other health care professionals.

Ability to work independently, prioritize tasks and demonstrate self-awareness as to when to seek assistance.

Proven ability to always maintain confidentiality and HIPAA compliance.

Possesses the knowledge and ability to drive operational metrics

Participates in the education and onboarding process of all new hires

Participates in the daily operations of the CDI team

Works in collaboration with HIMD’s/Coding managers to improve processes and performance

Work Experience, Education and Certifications:

EDUCATION: Licensed Registered Nurse, RHIA, RHIT, CCS, CDIP, CCDS, or other qualified Clinical Documentation Integrity professional required.Bachelor’s degree in Nursing, Health Information Management, Healthcare Administration, or related healthcare field preferred. For RN candidates, BSN preferred but not required.

EXPERIENCE: Minimum of 2-5 years acute clinical or coding (IP) experience preferred. A minimum of 5 years CDI experience required. Management/leadership experience preferred.

LICENSURE: Current unrestricted RN license required only if candidate is functioning under an RN credential. For non-RN candidates, RHIA, RHIT, CCS, CDIP, CCDS, or other applicable professional credential must be current and in good standing.

CERTIFICATION: CCDS or CDIP certification required. Candidates without CCDS or CDIP may be considered if otherwise highly qualified, but must obtain CCDS or CDIP certification within 6 months of hire.

SOFTWARE/HARDWARE: Proficiency in Microsoft applications, EMR applications, CDI and coding software

TRAVEL REQUIREMENTS:

May require occasional travel for meetings and onsite support to CDI teams in collaboration with CDI leadership

This is a remote position