Under general supervision of the CDI Manager following established policies, procedures and professional guidelines serves as a Lead CDI Specialist and second level reviewer for the department. The CDI Lead is an expert clinician who works in partnership with multidisciplinary teams, including but not limited to Coding, Quality, Infection Control and medical staff to improve the quality and accuracy of the medical record documentation. The CDI Lead monitors the accurate reporting of SOI/ ROM scores and MCC /CC capture rates for DRGs assigned. The CDI Lead maintains clinical and professional competencies for subject matter expertise in clinical documentation improvement concepts. They are responsible for concurrently reviewing inpatient medical records to identify vague, inconsistent or incomplete documentation within the medical record and assign the most appropriate medical severity diagnostic related group (MS-DRG). Further clarification of the principal and secondary diagnoses is carried out by collaborating with the physician(s) and/or care provider designees as appropriate. Participates in the educational and onboarding process of new team members.
- RN, Bachelors Degree · Certified Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS) or obtain and maintain certification within one year of employment
- Greater than 5 years clinical experience and greater than 3 years experience as a Clinical Documentation Improvement Specialist
- Preferred clinical experience with acute care experience at a large facility
- Preferred experience with 3M360 Clinical Documentation and EPIC electronic medical record.
- Excellent communication and interpersonal skills; ability to communicate verbally and in writing with individuals of varying educational levels
- Credible with Physician leadership
- Significant financial and analytical skills
- Word, Outlook, Excel PowerPoint experience preferred
- Analytical skills necessary to clinically assess medical records required.