Lead Clinical Documentation Specialist

Heartland Health • Saint Joseph, MO

45d

About The Position

This Position provides support, consultation, compliance to evidence-based care, and clinical documentation practices. Facilitates and drives improvements in the clinical performance initiatives and helps to maintain regulatory compliant documentation. Performance relies on general nursing/clinical knowledge, including pathophysiology, pharmacology, regulatory requirements and ACDIS professional guidelines. Advanced communication and education to a broad audience including medical staff, patients, clinical departments in the form of specific chart reviews and broad presentation/education. Collaborates regarding clinical and coding knowledge with key stakeholders within the organization. Responsibilities include concurrent review of the clinical documentation to obtain the most accurate and complete physician documentation that appropriately supports the severity of illness, risk of mortality and proper reimbursement. Possess a broad knowledge of documentation requirements for accurate ICD-10-CM/PCS coding requirement to assign correct DRG assignments. Provide leadership to the Clinical Documentation Integrity (CDI) team. This position works under the supervision of the Manager and is employed by Mosaic Health System.

Requirements

• All required education is a minimum requirement. Higher levels of education are acceptable. Associate's Degree in Health Informatics, Health Care Administration, Health Information Management, or Nursing required. OR Bachelor's Degree in Health Informatics, Health Care Administration, Health Information Management, or Nursing required.
• RN - Registered Nurse - State Licensure and/or Compact State Licensure (depending upon designated work location) required upon hire. AND state CCDS Certification - Certificated Clinical Documentation Specialist required upon hire. OR CDIP Certification - Certified Documentation Information Practitioner required upon hire.
• 5 years of clinical experience in an acute care setting, three of those are required to be in ICU\Critical Care required. AND 1 year of clinical Documentation Specialist (CDS) or Coding experience in an acute care facility required. AND In depth knowledge of CDI core concepts and processes and knowledge of Medicare Parts A and B, Official ICD-10-CM/PCS Coding Guidelines and quality initiatives required. AND Experience with clinical documentation improvement, utilization management, coding, billing, auditing various healthcare payers and knowledge of DRG classification system required.

Responsibilities

• Assists Inpatient Coding and CDI Manager with overseeing and leading daily workflow for CDI staff including distributing work assignments, follow-up on DRG Reconciliation, follow-up on Expired Patient Reviews, maintaining onsite CDI calendar, maintaining CDI floor rotation, reporting workflow and software issues as appropriate
• Assists Inpatient Coding and CDI Manager with monthly chart audits, quality audit, productivity metrics for CDI staff
• Assists Inpatient Coding and CDI Manager with identifying areas of education need for CDI Staff and providers
• Performs concurrent clinical documentation improvement reviews, documenting timely and completely in the clinical documentation improvement software.
• Acts as a second-level reviewer before escalation to Inpatient Coding and CDI Manager and/or HIS Medical Director.
• Other duties as assigned

Benefits

• Mosaic has a wide array of benefits to meet each employee's individual needs.
• Our benefits were designed by listening to people just like you.
• Mosaic also offers several perks with a focus on ensuring our employees feel valued, including concierge services, employee lounge, wellness programs, free covered parking, free on-site and virtual health clinics and many more.
• When paired with compensation and recognition, it is what continues to make us the employer of choice for employees at any stage of their journey.

What This Job Offers

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