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Job Summary:

Job Duties:

Work with CDI program leadership to plan, develop, and implement clinical documentation education programs for CDI specialists and providers. Develop a standard and comprehensive orientation and onboarding program for new members to the CDI team. Educate individuals and team members on the review functions within the CDI program in order to meet and maintain enterprise, goals and objectives, regulatory compliance, quality initiatives, policy and procedures, and personnel management. Create annual education based on coding and CDI industry updates, documentation gaps and trends, and evidenced based clinical care updates. Develops and promotes collaborative processes and strong working relationships with physicians and other health care professionals to accomplish program goals and ensure exceptional documentation.

This role is full-time, 40 hours weekly; 8:00 a.m.- 4:30 p.m., Monday through Friday.

A Bachelor's Degree in Nursing (BSN) is strongly preferred, plus 5 years RN work experience.

One of the following certifications is required and must be already completed at the time of application:

• Certified Clinical Documentation Improvement Practitioner (CDIP)

• Certified Clinical Documentation Specialist (CDS)

Job Duties:

• Mentor, educate and train CDI to effectively and accurately onboard new staff to the CDI role. Monitor and evaluate reviews of select records for opportunity and accurate capture of patient acuity, severity of illness, risk of mortality, quality measure and metric support, and DRG assignment in compliance with industry rules and regulations, for completeness and accuracy of the medical record.
• Monitors and provides feedback to the CDI team to ensure clinically credible, effective, and compliant practices.
• Tract and analyze trends to ascertain where stronger education is needed for both providers and staff.
• When documentation opportunity is identified, provide feedback to CDIS and monitor to determine if learning occurred and if it’s a departmental trend.
• If provider opportunity identified, collaborate with leadership and physician advisors.
• If coding opportunity is identified, coordinate with coder and/or Coding Manager to review and address opportunity, as applicable.
• Collaborate with Second Level Reviewers to identify opportunity trends and develop relevant training/education.
• Conduct individual and large group educational sessions for all CDIS and/or providers.
• Working closely with CDIS, identify areas of non-specific documentation and improve documentation and query templates in support of clinical treatment protocols.
• Collaborate with CDI managers, director, and other clinicians to facilitate the ongoing relevance of department specific orientation content, educational materials, documentation tip sheets, and other training programs/resources. 
• Maintains a summary of opportunities identified for feedback and education with the CDS team and reviews with managers and director regularly. 

Position Details:

Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.

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