Lead Clinical Documentation Specialist

Overview

The Clinical Documentation Specialist will work with Senior Director in physician education regarding documentation that meets severity of illness/intensity of service guidelines.  The CDS will work with hospital top DRG’s to insure that documentation is optimal and meets coding clinic guidelines in order insure optimal hospital reimbursement.  Prepares and presents reports pertinent to improvements and educational outcomes. 

Responsibilities

- Assisting with the scheduling of staff to assure appropiate coverage.-

- Running and reviewing regular reports through several sourcees and utilizing information to: Analyze data and key metrics to find issues and develop a fix.

-Identify opportunities for CDS staff and physicians.

- Track technology issues with process tools and make requests to IT to improve upon them.

- Track query escalation process, CDS/Coder collaboration, etc. Coordinate with CDI Director.

- Identifies trends and opportunities for improvement in clinical documentation.

-Assist running weekly huddles or monthly meetings for CDI team and providing feedback to the CDI Director on operational concerns.

-Providing feedback to CDI Director on physician response issues.

-Work with the CDI Director to develop and oversee new hire training and orientation programs. 

-Conduct audits of CDI queries and perform second level reviews.

- Identify DRG mismatches and manage and collaborate with Coding team on reconciling DRG mismatches.

-Develop montly educational topics for CDSs based on opportunities identified from second level reviews and query audits.

-Develop content and provide physician in-services as needed based on review if disagreed queries, ongoing opportunities, and physician process and outcome data.

Qualifications

-Registered nurse or other health care profession required.

-Three (3) years’ experience in a related position in Clinical or Health Information Management Department.

-Experience in ICD-9 and ICD-10, CPt-4 coding.