Lead-Clinical Documentation Specialists

HONORHEALTH Job Description Lead-Clinical Documentation Specialists Job Code: TBD Department: Varies FLSA Code: Exempt Reports to: Supervisor or Manager Revision Date: 2017-09-01 Location: HonorHealth Revised/Approved By: A.Scianna

JOB SUMMARY

Leads, provides and maintains clinical documentation improvement (CDI) practices to ensure consistency, meet corporate compliance guidelines. Performs analytical assessment of data, data manipulation, and professionally articulate data outcomes to improve operations. Works closely with the Clinical Denials, Quality Measures and Mortality Workgroup.

JOB RESPONSIBILITIES

(These are essential job responsibilities and should be listed in descending order of importance i.e. most important is first )

Percent of Time

Description

Serves as a subject matter expert in clinical data reporting and leads the improvement of the overall quality and completeness of clinical documentation through the application of evidence-based knowledge, analysis, in-depth review, interpretation, identification of opportunities, communication and consistent follow-up and evaluation of concurrent and retrospective (as required) medical record documentation. Monitor internal key indicator metrics associated with CDI as it related to the revenue cycle and quality outcomes. Works closely with Information Technology to fully understand system upgrades and testing.

Coordinates any and all computerized record upgrades, testing and quality improvement activities.

Performs analytical assessment of data, data manipulation, and professionally articulate data outcomes to improve operations and report to various committees, including but not limited to the Clinical Effectiveness Committee, monthly facility specific Utilization Review Committees and Chief Medical Officers. Performs quality reviews and presents findings to the CDI Manager and the CDI Educator in order to develop education for physician, and CDI staff as needed. May serve as a backup for CDI as a Specialist and/or Educator. Trains all Specialists and Educators where applicable.

Performs other duties as assigned.

TOTAL HONORHEALTH Job Description Lead-Clinical Documentation Specialists Job Code: TBD The above job responsibilities describe the general nature and level of work to be performed. It does not restrict management’s right to assign or re-assign duties at any time.

JOB QUALIFICATIONS

Minimum Preferred RN with Bachelor’s degree or 4 in lieu of degree in EDUCATION relevant experience as outlined in minimum RN with Master’s Degree experience 2 years of CDI experience and 1 year of supervisory experience; clinical 3-5 years of CDI experience. EXPERIENCE background with history of working in a critical 5 years management experience care area Verified current Arizona or other compact state RN license and Certified Clinical Documentation Specialist (CCDS) issued CERTIFICATION/ Verified current Arizona or other compact state by the Association of Clinical Documentation LICENSURE/ ETC.* RN license. Improvement Specialists (ACDIS) or Certified Documentation Improvement Practitioner (CDIP) issued by The American Health Information Management Association (AHIMA). SKILLS Vision Requirements: Vision: Acuity near (clarity at 20 inches or less) Ability to read English language Ability to write English language Hearing: Ordinary conversation Lifting: 25 pounds max: 10_% Neck up/down movement: _25_% Physical Job Requirements: Reaching: _25_% Sitting: _85_% Standing: _15% Verbal: Ability to communicate words and ideas Walking: _40_% Potential Environmental N/A Conditions: Working Conditions: Inside:100% Required Protective Equipment: Follows the policy and procedures of the department. Good working knowledge of ICD-10. Knowledge of Local Medicare Review Policies. Exposure to encoder software. Keeps current with federal legislation, periodicals and publications establishing current coding/reimbursement compliance. Ability to deal with physicians, peers, coworkers and customers with tact, discretion and diplomacy. Demonstrates skills in Other Skills: in oral and written communication. Ability to analyze CDI data and prepare PowerPoint presentations. General knowledge of Hospital Information Systems as well as extensive knowledge of computer systems/applications used in CDI. Ability to prepare an analyze data to drive performance and priorities for improvement. Flexible, organized, strong oral and written communication, utilize hospital authorized software applications. Area of Responsibility: Professional, Technicians, Analytical Level of Responsibility: Leads, trains others * It is expected that all certifications, licenses, etc. are renewed by the expiration date to remain compliant. HONORHEALTH Job Description Lead-Clinical Documentation Specialists Job Code: TBD The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. This description precludes any other description(s).

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