POSITION SUMMARY:

Following established policies, procedures, and professional guidelines, the Lead Clinical Documentation Specialist coordinates the prioritization and oversees the day-to-day workflow of the CDS staff and provides clinical documentation improvement expertise. This position requires an experienced Clinical Documentation Specialist who works in partnership with the Coding Compliance Manager and Physician Advisors to ensure high quality and production standards are met. This will be accomplished through data evaluation, direct observation and review of medical records, and daily staff communication. The CDS Lead is responsible for maintaining concurrent and retrospective review expertise to ensure accuracy, specificity, and severity captures are obtained consistently by all reviewers. This position will also resolve CDS-Coder DRG discrepancies working in collaboration with the Physician Advisor and Coding Supervisor. This position will also participate in various projects and initiatives within the CDS Department. The CDS Lead is expected to participate in the education and onboarding process of all new hires, perform duties and conduct interpersonal relationships in a manner that promotes a team approach and collaborative work environment with physicians, CDS staff and coders.