CDI Specialist Lead
The Lead ClinicalDocumentation Improvement Specialist provides onsite support of clinicaldocumentation improvement activities in an effort to support accuracy andquality in the patient records at Northwest Medical Center Tucson and OroValley Hospital and to ensure that coded diagnoses are an accurate reflectionof the patient's clinical status and care. The Lead CDIS provides a key role inmaintaining the long-term system success by providing an intense systemoversight of the program at the facility.
The Lead CDIS under the direction ofthe facility's Director Health Information Management (HIM) will be responsiblefor providing detailed assessments of Northwest Medical Center and Oro ValleyClinical Documentation Improvement Program and action plans designed to migratethe hospital's Best-Practice environment, and implementing the recommendedchanges identified in these action plans.
The Lead CDIS will report to theDirector Health Information Management and act as a liaison to the CorporateRegional CDI Director. Additional responsibilities include, but are not limitedto, development and delivery of onsite Physician and Clinical DocumentationImprovement Specialist (CDIS) education through a variety of modalities,coordination of CHS CDI audits, support of facility-level CDIS staffinginitiatives, and providing new clinical documentation specialist orientation todocumentation improvement activities.
This individual willpossess a broad knowledge of documentation requirements for accurate ICD-9-CM,ICD-10-CM/PCS and MS-DRG assignment. This knowledge will play a key role indetermining the reimbursement and quality potential of Northwest Healthcarefacilities.Adherence to official coding compliance regulations, corporate policiesdeveloped to ensure accurate billing, and industry best-practice is essential.
Degree concentrationin Health Informatics and Information Management, Health Care Administration,or clinical background such as Registered Nurse or comparable clinicalexperience.
ADN or Diploma inNursing Program, Clinical and Master's degrees highly desired.
Must possess atleast five years of acute hospital nursing experience (e.g. medical/surgicalunit, intensive care). Minimum of three years of clinical documentationimprovement experience in ICD-9-CM and MS-DRGs
Three years ofexperience in providing physician and/or PHIIP education required, or similarclinical background experience providing education
Experience inUtilization Management/Case Management, Critical Care, patient outcomes/qualitymanagement and/or inpatient coding, ICU/Critical Care, clinical documentationimprovement, ICD coding and MS-DRGs, working in a clinical documentationimprovement department or as a consultant and minimum of one (1) yearauditingexperience ."
"Must possess acomprehensive knowledge of medical terminology, disease processes and clinicalcompetency. Candidate must possess excellent interpersonal, collaboration andrelationship-building skills. Strong criticalthinking skills and ability to integrate knowledge is necessary. Prioritizationand organizational skills required. Must exhibit the ability to educate membersof the healthcare team about clinical documentation. Individual mustdemonstrate data quality and integrity skills.
To perform this jobsuccessfully, an individual should have strong working knowledge of wordprocessing software, spreadsheet software and reporting software. Also, experienceworking with encodersoftware, clinical documentation improvement software and the electronicmedical record is preferred.
English is requiredfor both verbal and written communication. Ability to communicate effectively at a high level isrequired."