Clinical Documentation Improvement Educator - Full Time
Lake Charles Memorial Health System, Lake Charles, LA, United States
Overview
Work with program leadership to plan, develop, and implement clinical documentation education programs for CDI specialists and providers. Educate members of the CDI team on the review functions within the CDI program to meet and maintain enterprise goals and objectives, regulatory compliance, policies and procedures and personnel management.
Supervision
Reports directly to the Director of CDI.
Responsibilities And Duties
Work with program leadership to plan, develop, and implement clinical documentation education programs for CDI specialists and providers.
Audits case reviews and queries of Clinical Documentation Specialists (CDIS) to ensure quality and compliance, using audit tools developed.
Tracks, trends, and reports audit findings for each Clinical Documentation Specialist (CDIS) to Director/management team.
Identifies knowledge gaps and provide clear explanations and interpretations on missing, unclear, conflicting, or non-compliant information captured by the CDIS.
Researches, investigates, and remains up to date on both clinical and coding guidelines in quarterly Coding Clinics as they relate to physician documentation improvement needed, in an ICD-10 coding environment.
Assists in overall quality, timeliness, and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes.
Responsible for using audit tools to conduct clinical quality audits.
Develops and updates policies and procedures around the CDIS audit function; and refine audit tools as needed in collaboration with Director/management team.
Will be responsible with working with CDI Leadership to mentor/train new CDI based on CDI orientation procedures.
Analyze data to ascertain where stronger education is needed for both providers and staff.
Serve as a mentor, resource for appropriate clinical documentation and educate CDI staff.
Conduct individual and large group educational sessions for all CDI Specialists and/or providers.
Collaborate with CDI Director and other clinicians to facilitate the ongoing relevance of department specific orientation content, educational materials and documentation tip sheets and training programs/resources.
Certification, Registration, or Licensure Required
Must have one of the certifications/licensures: Licensed Registered Nurse (BSN), Medical Graduate, Physician Assistant.
At least one of the following is required: CCS, CCDS, CDIP, RHIA or RHIT; preferably AHIMA or ACDIS Approved CDI Trainer.
Minimum 3 years CDI experience in an acute care setting. Teaching or training experience is a plus.
Knowledge of ICD-10-CM, ICD-10-PCS, CPT/HCPCS, MS-DRG, APR-DRG and APC coding guidelines.
Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required.
Demonstrated competency in teaching/learning process, organizational skills and computer literacy required.
Excellent communication skills and professional demeanor is required.
Ability to perform computer data entry (Experience with Word, Excel).
Ability to utilize EHR and entry of data in CDI software, including reconciliation and reporting of data.
Ability to build presentations/present Clinical Documentation Improvement to providers fluently.
Ability to work with CDI and/or Coding staff with ongoing education.
Ability to train and mentor new CDI staff with onboarding and education.
Physical Demands/Work Environment
Work requires a variety of physical activities, including moving about within and outside of all hospital properties for long periods of time.
Must be able to respond quickly and effectively to emergency and non-emergent situations.
May be required to assist in controlling disorderly conduct or combative patients.
Must be able to exchange accurate information with patient, family, peers and medical personnel.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Additional Information
The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.
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Work with program leadership to plan, develop, and implement clinical documentation education programs for CDI specialists and providers. Educate members of the CDI team on the review functions within the CDI program to meet and maintain enterprise goals and objectives, regulatory compliance, policies and procedures and personnel management.
Supervision
Reports directly to the Director of CDI.
Responsibilities And Duties
Work with program leadership to plan, develop, and implement clinical documentation education programs for CDI specialists and providers.
Audits case reviews and queries of Clinical Documentation Specialists (CDIS) to ensure quality and compliance, using audit tools developed.
Tracks, trends, and reports audit findings for each Clinical Documentation Specialist (CDIS) to Director/management team.
Identifies knowledge gaps and provide clear explanations and interpretations on missing, unclear, conflicting, or non-compliant information captured by the CDIS.
Researches, investigates, and remains up to date on both clinical and coding guidelines in quarterly Coding Clinics as they relate to physician documentation improvement needed, in an ICD-10 coding environment.
Assists in overall quality, timeliness, and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes.
Responsible for using audit tools to conduct clinical quality audits.
Develops and updates policies and procedures around the CDIS audit function; and refine audit tools as needed in collaboration with Director/management team.
Will be responsible with working with CDI Leadership to mentor/train new CDI based on CDI orientation procedures.
Analyze data to ascertain where stronger education is needed for both providers and staff.
Serve as a mentor, resource for appropriate clinical documentation and educate CDI staff.
Conduct individual and large group educational sessions for all CDI Specialists and/or providers.
Collaborate with CDI Director and other clinicians to facilitate the ongoing relevance of department specific orientation content, educational materials and documentation tip sheets and training programs/resources.
Certification, Registration, or Licensure Required
Must have one of the certifications/licensures: Licensed Registered Nurse (BSN), Medical Graduate, Physician Assistant.
At least one of the following is required: CCS, CCDS, CDIP, RHIA or RHIT; preferably AHIMA or ACDIS Approved CDI Trainer.
Minimum 3 years CDI experience in an acute care setting. Teaching or training experience is a plus.
Knowledge of ICD-10-CM, ICD-10-PCS, CPT/HCPCS, MS-DRG, APR-DRG and APC coding guidelines.
Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required.
Demonstrated competency in teaching/learning process, organizational skills and computer literacy required.
Excellent communication skills and professional demeanor is required.
Ability to perform computer data entry (Experience with Word, Excel).
Ability to utilize EHR and entry of data in CDI software, including reconciliation and reporting of data.
Ability to build presentations/present Clinical Documentation Improvement to providers fluently.
Ability to work with CDI and/or Coding staff with ongoing education.
Ability to train and mentor new CDI staff with onboarding and education.
Physical Demands/Work Environment
Work requires a variety of physical activities, including moving about within and outside of all hospital properties for long periods of time.
Must be able to respond quickly and effectively to emergency and non-emergent situations.
May be required to assist in controlling disorderly conduct or combative patients.
Must be able to exchange accurate information with patient, family, peers and medical personnel.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Additional Information
The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.
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