Lead Clinical Documentation Specialist
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 III performance, with an additional emphasis on management responsibilities and expanded scope of oversight. The CDIS Lead provides support to the CDI Manager and 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.
• 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 report KRONOS time
• Will assume operational oversight in the absence of the CDI Manager
• 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 on new coding
guidelines, policies/procedures, federal and state reimbursement.
• All tasks must be performed in accordance with the established Steward CDI daily workflow 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 Manager, 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 Steward CDI Program goals and standards.
• Actively supports Steward CDI program initiatives implemented by Steward Corporate leadership.
REQUIRED KNOWLEDGE & SKILLS:
• 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 demonstrates self-awareness as to when to seek assistance.
• Proven ability to maintain confidentiality and HIPAA compliance at all times.
• 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 team
• Works in collaboration with the HIMD’s/Coding managers to improve processes and performance
I. Education: Bachelor’s degree in a clinical or coding study is preferred. Master’s degree in a health care or related field is preferred.
II. 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.
III. Licensure: RN current State License
IV. Certification: CCDS or CDIP certification is required.
V. Software/Hardware: Proficiency in Microsoft applications, EMR applications, CDI and coding software