General Summary of Position
Provides ongoing education to Clinical Documentation Improvement staff system wide. Provides education and training to newly hired Clinical Documentation Specialists. Collaborates with the Director of CDI in the development of educational materials. Participates in the department quality audit processes by performing assigned audits, communication of findings, and data entry for reporting. Collaborates with Medical Staff Leadership in the ongoing education efforts involving clinical documentation improvement.
Primary Duties and Responsibilities
Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.Assists the CDI Director with annual staff competencies and evaluations.Collaborates with Physician leadership in the provision of ongoing education to physicians, and physician extenders regarding clinical documentation regulatory requirements and best practices.Collaborates with the Director of CDI in the system wide CDI quality audit process, to include completion of audits, associated data entry, and communication of audit results to CDI staff.Collaborates with the Director of CDI to provide monthly training for Clinical Documentation Specialists and quarterly training for CDI and Coding staff.Monitors CDI staff compliance with all assigned training modules, including annual training on the SiTEL LMS.Provides continuing education for Clinical Documentation Improvement staff system wide.Provides initial training and education for newly hired Clinical Documentation Improvement staff system wide.Participates in meetings and on committees and represents the department and hospital in community outreach efforts.Participates in multi-disciplinary quality and service improvement teams.Performs other duties as assigned.
Minimum Qualifications
Education
- High School Diploma or GED required and
- Bachelor's degree in Nursing preferred and
- Doctoral degree preferred
Experience
- 5-7 years Experience in acute care setting. Experience in working with physicians and clinical professionals. Experience in the clinical documentation specialist role. Experience in documentation review including coding and DRG analysis. required
Licenses and Certifications
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
- MD - Physician - State Licensure required and
- CCDS - Certified Clinical Documentation Specialist required or
- CDIP - Clinical Documentation Improvement Practitioner required and
- CCS-Certified Coding Specialist preferred
Knowledge, Skills, and Abilities
- Knowledge of Maryland rate setting and reimbursement under the CMS waiver a plus.
- Knowledge of inpatient acute care clinical conditions and supporting clinical indicators with appropriate code assignment
- Knowledge of The Joint Commission, HIPAA, ACDIS/AHIMA Query Brief, and other regulatory requirements.
- Basic computer skills including working knowledge of CDI, EHR, and microsoft software applications.
- Excellent interpersonal skills, including verbal and written communications.
- Good public speaking and presentation skills, attention to detail, follow up on outstanding issues, and ability to organize and meet deadlines.
This position has a hiring range of $93,142 - $166,795
