Clinical Documentation Improvement Lead

Jefferson Health System

$85K — $100K *
Hospitals & Medical Centers
Less than 5 years of experience
Job Overview by Ladders

Qualifications

  • 3+ years as a CDI specialist required.
  • Associate or Bachelor of Science in Nursing, Medical degree, or related clinical health profession.
  • Alternatively, 5 years of inpatient acute care medical coding experience accepted.
  • Certified Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement Practitioner (CDIP) certifications required.
  • Strong background in clinical record reviews and EHR systems.

Responsibilities

  • Serve as a key resource for workflow and operations support.
  • Conduct training and mentoring for staff to improve documentation skills.
  • Assist staff with daily questions and escalate issues as needed.
  • Manage personal work queues to ensure timely completion of tasks.
  • Validate monthly reports for staff, providers, and leadership.

Benefits

  • Comprehensive medical, dental, and vision insurance.
  • Flexible spending accounts and retirement plans available.
  • Tuition assistance and discounts after qualifying period.
  • Access to group rates on insurance and discounts for voluntary benefits.
  • Short- and long-term disability coverage included.
Full Job Description

Job Details

Lead CDI Specialist

Job Description

Under the direction of the Senior Director of Revenue Cycle, Clinical Documentation Improvement (CDI) and Revenue Cycle Manager, CDI, the Revenue Cycle Lead, CDI  serves as an expert resource for staff and functions to assist supervisory staff in assigned area with workflow and day-to-day operations.  This position will support organizational goals by identifying opportunities to partner with providers to provide education and feedback regarding documentation so that it reflects all diagnoses.  

1. Interacts with coworkers, visitors and other staff consistent with the values of Jefferson Health.

2. Assist supervisory staff in areas of workflow, staff performance, and day-to-day operations to ensure that department goals are met.

3. Conduct training and mentoring sessions for new and existing staff.

4. Assist employees with day-to-day questions, issues, or problems and escalate identified systemic issues to supervisor.

5. Manages own assigned work queue(s).

6. Validation of monthly reporting for staff, providers, and leadership.

Strong working knowledge and experience in clinical record reviews, 3M encoder coding systems, DRG system, and Epic EHR system.  
Expert level working knowledge of ICD-10 CM/PCS coding conventions and SOI/ROM required. 
Excellent interpersonal, organizational,  and communication skills.
Strong working knowledge of Microsoft Office; Outlook, Word, Excel, PowerPoint. 
Ability to work independently and as a team member.
Effective problem-solving skills required. 
Must be able to meet departmental goals on an ongoing basis.
Awareness of compliance and regulatory guidelines 

Required Knowledge, Skills, and Abilities (Proficiencies):

Minimum three years' experience required as a CDI specialist. Associate or Bachelor of Science in Nursing; Medical Graduate degree or Associate/Bachelor Degree in other clinical health profession. Minimum of three years hands-on clinical experience either obtained through clinical experience in nursing (i.e. RN, BSN), medical school, respiratory therapy, physicians assistant, or residency or 5 years of inpatient acute care medical coding experience. 

Required Experience, Education, Certification(s), License(s):

Certified Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement Practitioner (CDIP) certifications required.

Preferred:

BSN, PA or medical graduate degree. Prior experience in CDI at a large academic medical center. 



Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Thomas Jefferson University

Primary Location Address

1111 Sansom Street, Philadelphia, Pennsylvania, United States of America

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

For more benefits information, please click

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