Lead Clinical Documentation Specialist - Utilization Management

UR Medicine Thompson Health • Canandaigua, NY

6d • Remote

About The Position

Performs extensive medical record review through the use of CDI software integrated with the EMR. Facilitates clinical documentation improvement through concurrent and retrospective interaction with physicians and members of the healthcare team. This interaction supports the clinical severity of the inpatient admission, quality documentation standards that align with federal and state regulations and assists with maximizing revenue and risk stratification. Act as the lead for the CDI team and assist with coordination of clinical documentation improvement practices consistent with corporate compliance guidelines and appropriate financial reimbursement based on the acuity of the patient population. Oversee training and education for providers, nurses and other CDI staff. Actively participate in team and committee meetings to assist with the development of improvement efforts and education regarding the Clinical Documentation Management Program (CDMP).

Requirements

• Advanced Clinical Knowledge: including comprehensive understanding of anatomy, physiology, and disease processes
• Expertise in coding and reimbursement methodologies
• Clinical documentation principles: a strong grasp of compliant clinical documentation practices
• Effective physician querying: ability to formulate clear, concise and non-leading queries to physicians and other providers
• Auditing and Quality Assurance: proficiency in conducting retrospective and concurrent review of medical records
• Data Analysis and Reporting: ability to analyze CDI program date, identify trends in documentation and measure program effectiveness
• Education and training development: skill in developing and delivering targeted education and training programs for physicians, advanced practice providers, residents, and other healthcare staff on documentation best practices
• Leadership and mentorship: ability to lead a team of CDI specialists, provide guidance, mentorship and constructive feedback. Foster a collaborative and high-performing work environment
• Technology proficiency: competence in utilizing electronic health record systems, CDI software and other relevant healthcare information technology
• Adherence to all relevant health care regulations and hospital policies related to patient privacy (HIPAA), documentation, and billing
• Licensed RN with minimum of 5 years inpatient clinical experience and extensive knowledge of complex disease processes.
• CDS (Clinical Documentation Specialist) or CDIP (Clinical Documentation Improvement Practitioner certification required within two years of starting the role.
• AAS required
• Minimum 3-5 years CDI experience
• Proficiency with computers, spreadsheets and Microsoft office

Nice To Haves

• BSN preferred or willingness to complete within 5 years of hire
• Leadership experience preferred
• Advanced clinical experience with extensive knowledge of complex disease processes preferred

Responsibilities

• Performs extensive medical record review through the use of CDI software integrated with the EMR.
• Facilitates clinical documentation improvement through concurrent and retrospective interaction with physicians and members of the healthcare team.
• Supports the clinical severity of the inpatient admission, quality documentation standards that align with federal and state regulations.
• Assists with maximizing revenue and risk stratification.
• Acts as the lead for the CDI team and assists with coordination of clinical documentation improvement practices consistent with corporate compliance guidelines and appropriate financial reimbursement based on the acuity of the patient population.
• Oversees training and education for providers, nurses and other CDI staff.
• Actively participates in team and committee meetings to assist with the development of improvement efforts and education regarding the Clinical Documentation Management Program (CDMP).

Benefits

• competitive pay
• tuition assistance
• free parking

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree