This position assists with the development of education / training materials, conducts and coordinates training and development of the centralized system Clinical Documentation Improvement staff as appropriate, including documentation related education presented to physicians/providers. Creates and maintains all department training materials, tools, and/or documents. Participates as a Clinical Documentation Improvement (CDI) Subject Matter Expert, ICD-10 trainer, and assists with concurrent peer evaluation and education. Conducts new hire skill assessments, department specific orientation and training for work tasks and functions. Provides ongoing, continuing education, and conducts annual competency assessments.
- Assists in the planning, delivery, and evaluation of the standardized and centralized educational efforts of the system Clinical Documentation Improvement program in conjunction with organizational goals and objectives.
- Assesses and identifies skills, competencies and areas of learning and instruction needed for all CDI staff. Assists with the development of education and training, which may include preparation of related educational materials and development of cost-effective training programs that will increase the productivity of all employees. Develops, implements, and maintains tools to assess and measure CDI staff against position specific competencies.
- Provides oversight and participation with the planning and coordination of the orientation programs for new hires; provides introduction to the program, clarifies program expectations and standards; provides prerequisite knowledge required; and assists to train in the basic job skills. Through education, coaching and mentoring builds CDS comfort in the role from both a clinical perspective and coding knowledge perspective. Provides for onsite support of trainees, and acts as a CDI knowledge resource for staff, providers, leadership teams, and otherhealthcare professionals. Helps develop, train, evaluate and maintain CDS Apprenticeship program.
- Develops and maintains an education calendar; facilitates tracking mechanisms for individual continuing education and orientation records for staff. Develops and conducts programs with educational materials, procedures and exercises that are task/function specific using a variety of learning and evaluation strategies for all staff.
- Works in regional/system-wide teams to collaboratively design and develop educational/promotional materials and programs to effectively communicate clinical documentation improvements with health care providers. Develops strategic plans for educating health care providers utilizing a variety of teaching/educational methods to ensure successful outcomes. Promotes standardized practices for CDI-related provider education throughout the organization.
- Maintains working knowledge and ability to configure and troubleshoot applications/equipment used in providing data. Assists in staff education regarding data report interpretation. Utilizes data in the most efficient manner and presents data in the most effective and appropriate display for the intended audience.
- May collect and/or coordinate the collection of data, compile reports and graphs and present findings at Medical Staff Committee meetings, Health Information Management System meetings, Clinical Documentation Specialist meetings and/or other appropriate department, facility and system level meetings. May also coordinate, perform or participate in clinical pertinence and inter-disciplinary chart reviews, ensuring the reviews meet government and regulatory standards.
- Maintains a current knowledge relating to Clinical Documentation Improvement by attending educational workshops/conferences, reviewing professional publications, establishing personal networks, and/or participating in professional societies. This may also include performing ongoing research to ensure compliance with clinical documentation and/or regulatory guidelines and standards.
Requires a level of education as normally obtained through the completion of a bachelors degree in nursing.
Requires Registered Nurse (R.N.) license in state worked.
Requires a proficiency level typically attained with 5 years acute-care, inpatient hospital clinical experience. Must have the ability to work independently, possess demonstrated critical thinking skills, problem-solving abilities, and effective written and verbal communication skills and time management skills. Must also demonstrate the ability to work effectively within an interdisciplinary team format.
Must pass a written clinical competency examination with minimum score of 70.Requires strong working knowledge of clinical documentation methodologies as typically obtained through a minimum of 3 years relevant experience, including solid understanding of MS-DRGs, coding rules, regulations, and guidelines; identification of documentation improvement opportunities; and clarification guidelines.
Previous training/teaching experience and coaching/mentoring experience preferred. Creativity and knowledge of adult learning principles preferred.Previous experience with EMRs, CDI/Coding IT applications preferred.Clinical Documentation Improvement Certification
Additional related education and/or experience preferred.
Job Number 213963