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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.

• Always maintains utmost level of confidentiality and integrity.
• Adheres to hospital policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines. 
• Serves as a subject matter expert for the CDI program, inpatient coding, and reimbursement methodologies.
• Demonstrates ability to educate medical and hospital staff regarding the MS-DRG and APR-DRG reimbursement methodologies.
• Assists HIM management with coordination of CDI compliance reviews.
• Communicates with hospital personnel regarding questions relevant to CDI, inpatient coding, and reimbursement.
• Assists HIM management in communicating with physicians and other clinicians concerning opportunities for improvement relevant to clinical documentation and its impact on reporting.
• Assists HIM management in the development and maintenance of hospital specific CDI, reporting and billing guidelines.
• Attends hospital committee meetings as needed.
• Monitors and evaluates case mix patterns and trends.
• Reviews and codes inpatient medical records as needed for additional backlog and reporting support.
• Assists with special projects as assigned by HIM management.
• Must maintain current knowledge of reimbursement systems and federal, state and payer-specific regulations and policies.
• Must demonstrate continuing education in CDI, inpatient coding, and/or reporting compliance areas.
• Completes initial reviews timely in order to promptly identify potential documentation improvement opportunities.

• Conducts follow-up reviews of patients as scheduled 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 to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to assign ICD-9-CM and ICD-10-CM/PCS diagnosis and procedure codes to determine an accurate working and final APR-DRG, severity of illness, and/or risk of mortality.

• Assists in the appeal process resulting from third-party reviews.

• Proficiency in the use of Microsoft applications (e.g. Word, Excel, PowerPoint), Epic, and 3M CRS and 3M CDI 360 Encompass.

Education and/or Experience:

• RHIA, RHIT, CCS, CDIP, or CCDS certification preferred with a minimum of two years ICD hospital-based coding experience or are clinical candidates minimally credentialed or above 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.
• Proficient in polished communication skills, Outlook, Word, and Excel.

Certificates, Licenses, Registrations.

• RHIA, RHIT, or CCS certification preferred or eligible – to be achieved within 2 years of employment. CDIP or CCDS certification preferred or eligible – to be achieved within 3 years of employment.