Lead CDI Specialist

 About Us:

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. 

We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.  

JOB SUMMARY:

The Clinical Documentation Integrity Lead is responsible for assisting and supporting leadership in planning, directing, and controlling all aspects of the day-to-day operations for the Clinical Documentation Integrity (CDI) program by establishing a collaborative rapport with CDI Specialists, department leadership, and providers (Physicians, Advanced Practice Professionals and Medical Residents where applicable). The Lead is also responsible for facilitating improvement in the overall quality, completeness, and accuracy of the medical record documentation through extensive audit investigation, education, and data analysis. Responsible for working with physicians, coders, ancillary department staff, CDI, and other allied health professionals to improve documentation of patient care and to appropriately assign codes and/or determine charges to support those services. When needed, perform pre-bill compliance audits to ensure accurate code assignment, application of coding guidelines, and compliance with external regulatory and accreditation requirements. Identifies solutions to improve the overall data quality of the health records and to ensure appropriate reimbursement is obtained for services provided.

ESSENTIAL DUTIES AND RESPONSIBILITIES: 
Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member.

• Perform routine QA for seasoned team members
• Timely communication of QA concerns to manager
• Provide client specific orientation for new team members, maintaining consistent, high quality, expert level of experience (when and where applicable)
• Facilitate the process and support team members moving to a different staffing project
• Serve as a resource for team members for daily issues
  • connectivity/software/etc.
  • second level reviews
  • query assistance
• Assist with maintenance of CDI Workbooks to ensure accurate and timely data capture and reporting
• Will align as back up for Staffing
  • Combination of scheduled hours, coverage for vacancies, and coverage for PTO
• Attend client meetings as needed
• Assist CDI Manager in maintaining and updating SharePoint folders for assigned projects
• Other duties as assigned by management
• Average 20 billable hours weekly

MINIMUM QUALIFICATIONS & REQUIREMENTS:

• Requires a minimum of three (3) years of experience as a Clinical Documentation Integrity Specialist.
• Requires a Bachelor’s (preferably BSN) degree in a relevant field; or an Associate of Science n Nursing (ASN) degree and two (2) years of relevant clinical work experience in an acute care inpatient setting can substitute for a required degree.
• Requires Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) certification within one (1) year along with the maintaining of required Continuing Education Units (CEUs) thereafter.
• Regular, predictable, attendance is required.
• Must be proficient in Microsoft programs like Excel and Outlook. Examples include:
  • Excel you should be able to open and add to a spreadsheet, perform basic formulas like adding or multiplying.
  • Outlooks you should be able to manage emails and schedule and attend meetings.
• Ability to communicate effectively and professionally both verbally and written.
• Ability to coordinate, analyze, observe, make decisions, and meet deadlines 
• May be required to perform other duties as assigned by Leadership Team Member.

PHYSICAL DEMANDS:
Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.
A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.