Clinical Documentation Specialist Lead

Clinical Document Improvement


Bachelors degree is required
3-5 years experience is required

The Clinical Document Improvement Specialist Lead - (LCDS) is responsible for providing CDI program oversight and day to day CDI implementation of processes related to the concurrent review of the clinical documentation in the inpatient medical record. The goal of the LCDS oversight and practice is to support the CDI manager function by providing staff oversite, serve as an additional resource as well as perform CDI role function. LCDS will assess the technical accuracy, specificity, and completeness of provider clinical documentation, and to ensure that the documentation explicitly identifies all clinical findings and conditions present at the time of service. 

This position collaborates with CDI manager, providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decisions, and diagnoses for the patient. The LCDS utilizes clinical expertise and clinical documentation improvement practices as well as facility specific tools for best practice and compliance with the mission/philosophy, standards, goals and core values of Central Maine Healthcare. This position does not have patient care duties, does not have direct patient interactions, and has no role relative to patient care.

Lead CDI Responsibilities:
Assists Manager with chart audits, quality audit and KPI audits 
Assists Manager with running reports, attends on site meetings as directed 
Assists CDI staff training and orientation 
Oversees and leads workflow for CDI staff 
Develops physician teaching and on site presentations 
Assist Manager with projects or tasks as needed 
Primary Responsibilities:
Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the patient condition and acuity of care provided 
Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity 
Provides expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating recommendations for improvement, and the rational for the recommendations 
Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality 
Performs regular rounding with unit-based physicians 
Provides face-to-face educational opportunities with physicians on a daily basis 
Provides complete follow through on all requests for clarification or recommendations for improvement 
Leads the development and execution of physician education strategies resulting in improved clinical documentation 
Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes 
Ensures effective utilization of the Optum CDI tool, documenting all verbal, written, electronic clarification activity 
Proactively develops a reciprocal relationship with the HIM Coding Professionals 
Coordinate and conducts regular meeting with HIM Coding Professionals to monitor retrospective query rate and address issues 
Engages and consults with Physician Advisor when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process 
Actively engages with Care Coordination and the Quality Management teams to continually evaluate and spearhead clinical documentation improvement opportunities
Professional Development
Attend local and regional conferences/seminars to remain current in supporting the needs of the organization.
Review industry publications to maintain knowledge base and stay current on best practice solutions.
Maintain certifications as applicable
Maintain membership with professional associations (ACDIS, AHIMA, AAPC etc.)

Note: the duties listed above reflect the majority of the duties of this job and does not, nor is it intended to, reflect all duties that may be required for an incumbent in this job to perform.

Education and Experience:
5+ years acute care hospital clinical RN experience 2+ years of experience in Clinical Documentation Improvement 
Current Licensure from the Maine State Board of Nursing.
CCDS, CDIP or CCS certification preferred
BSN degree or equivalent preferred 
Knowledge, Skills, and Abilities:
Previous experience in case management and / or critical care
Must have proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point and Electronic Medical Records 
Seek and recommend new information technology solutions and or manual changes that support CDI and Coding functions.
Work collaboratively with departmental personnel to implement systems and process changes aimed at improving CDI performance.
Knowledge of familiarity with healthcare payer requirements, including ICD coding and DRGs
Proficient in the use of the Optum CDI tool, documenting all verbal, written, electronic clarification activity
Review and analyze on-going CDI KPI's based on computer generated data and manual reports.
Utilize departmental work plans to monitor initiative and project goals, progress, and outcomes.
Expertise with regulations and accreditation standards, knowledge of specific state and federal requirements and standards. 
Working knowledge of Medical Record, Financial Services and Healthcare Application technology.  
Proficient in computer use, including database and spreadsheet analysis, presentation programs, word processing and internet searching.
Demonstrates interpersonal relationships in a manner that enhances communication, promotes conflict resolution and facilitates staff development.
Ability to ensure a high level of employee, patient, visitor, and external stakeholder satisfaction.
Ability to positively influence change.  
Ability to work independently.
Excellent communications skills, both oral and written.  
Demonstrated ability to work well with diverse people, excellent human relation skills.
Flexible and able to react to ever changing priorities.
Experience communicating & working closely with Physicians

Employee Referral Bonus Eligible!