Job Description:
• Collaborate with CDI leadership, coding teams, providers, auditors, and operational leadership to improve documentation and coding accuracy
• Assess provider and CDI team knowledge and skill gaps using data trends, CDI KPIs, audit results, industry events, and leadership needs
• Develop, tailor, and deliver live and recorded CDI education and training
• Train providers on documentation best practices and clinical documentation specialists on operations, skills, teamwork, customer service, and change management
• Conduct new employee orientations, skills development, and new-user technology training
• Create education materials, training materials, presentations, and meeting resources
• Provide timely follow-up education based on CDI and Coding audit results and query activity
• Assist with testing future CDI technology enhancements and function as a super user for CDI software and applications
• Review clinical documentation remotely during patient admissions
• Perform hospital-wide medical record reviews to improve completeness, accuracy, coding compliance, reporting, and patient outcomes
• Submit compliant electronic queries to clinicians and provide appropriate follow-up
• Escalate unanswered queries according to the Wellstar Query Escalation process
• Reconcile records daily in the Solventum/3M 360 Encompass CDI tool
• Review Coding Clinic changes and maintain current knowledge of coding, billing, medical terminology, procedures, medications, and diseases
• Participate in required meetings, conference calls, and stakeholder presentations
• Support regulatory compliance and departmental policies
• Perform other duties as assigned
Requirements:
• Associate's degree in Nursing, bachelor's degree in Health Science, accredited Health Science program, or Doctorate of Medicine
• Certified Clinical Documentation Specialist within 180 days of hire or Certified Documentation Improvement Practitioner within 180 days of hire
• Minimum 2 years working in an acute care setting as a Clinical Documentation Specialist (CDS)
• Minimum 5 years of healthcare experience
• Strong understanding of disease processes, clinical indications, treatments, and provider documentation requirements
• Knowledge of Medicare, Medicaid, and commercial payer coding and billing rules
• Familiarity with an encoder and current working knowledge of Coding Clinic Guidelines and federal updates to MS and APR DRG systems
• Expert knowledge/experience in Clinical Documentation Integrity, including productivity, quality, education and training, compliance auditing, data analysis and trending, report management, and performance improvement initiatives
• CDI/Coding chart review experience
• Excellent communication, presentation, problem-solving, time management, training, and peer development skills
• Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives
• Proficient computer skills in Microsoft Word, Excel, PowerPoint, and CDI technology tools
• Comfortable performing data analysis and preparing and maintaining records and written reports
• Ability to leverage technology and reporting capabilities to identify education opportunities
• RNs must be licensed, knowledgeable, and uphold nursing practice standards upon hire
• Non-clinical/coding candidates must have at least one active/current CCS, CPC, RHIA, or RHIT certification upon hire
Benefits:
• Virtual/remote work arrangement
• Supportive work environment
• Meaningful work in healthcare
• More rewarding life and employee support