Lead Clinical Documentation Specialist (Hybrid), Day Shift, Clinical Documentation

Adventist HealthCare • Gaithersburg, MD

1d • $89,357 - $134,035 • Hybrid

About The Position

Adventist HealthCare Support Center seeks to hire an experienced Lead Clinical Documentation Specialist who will embrace our mission to extend God’s care through the ministry of physical, mental, and spiritual healing. As a Lead Clinical Documentation Specialist you will: • Run daily operations for assigned sites: staffing coverage, workload/meeting cadence, workload balancing, weekend/holiday coverage plan. Develops, implements, and maintains formal and informal CDI education & training on clinical documentation and CDI software for a variety of disciplines, utilizing multiple approaches based on identified needs. Reviews and validates CDI impact charts to confirm accuracy • Provide real-time clinical review for tough cases (ICU acuity, procedures, cardiology/cardiac surgery, sepsis/resp failure, shock, encephalopathy, malnutrition, etc.) and escalate as appropriate to ensure there is appropriate SOI/ROM • Review department data for quality and accuracy, identifying trends, systemic issues and factors contributing to inaccurate data impacting quality and patient safety • Conducts educational programs related to documentation improvement opportunities, coding and reimbursement issues, as well as performance improvement methodologies for internal customers and physicians. Analyzes and compiles accurate and complete data for statistical reporting and educational presentations, as needed • Communicates and interacts with physicians and clinical staff via informal verbal communication, the use of written communication tools, and formal educational presentations. Utilizes research, analytic data, and observations to provide recommendations to improve the overall quality and completeness of clinical documentation • Collaborate with Quality reviewer to go over MHAC, PSI, PPC documentation risks • Performs concurrent and retrospective reviews of the medical record (as needed), utilizing evidence-based knowledge, protocols, and criteria. Facilitates modifications to support clinical documentation of health team members to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a focus on physician documentation, inpatients and DRG payers. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart • Assisting and supporting leadership in planning, directing, and controlling all aspects of the day-to-day events in CDI department

Requirements

• Doctor of Medicine (MD), Doctor of Osteopathy (DO), Foreign Medical Graduate (FMG), Registered Nurse (RN), Doctor of Physical Therapy, Pharmacist
• RHIA, RHIT, or related clinical/allied health degree
• Minimum of 7 years inpatient clinical experience
• 2+ years of clinical documentation, coding, case management, utilization review, or acute-care clinical experience
• Experience interpreting physician documentation, lab results, imaging, and clinical indicators.
• CCDS (Certified Clinical Documentation Specialist), CDIP (Clinical Documentation Improvement Practitioner) or equivalent required and active
• Maintains current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS, APR, AP etc)
• Knowledge of medical terminology, anatomy, physiology, microbiology, and disease processes.
• Proficient in Microsoft office

Nice To Haves

• Experience with ICD-10-CM/PCS, DRGs, SOI/ROM or HCC is a plus
• Lean Six Sigma Green belt preferred
• Solventum360 preferred
• Certified Documentation Expert Inpatient (CDEI) preferred
• Certified Coding Specialist (CCS) preferred

Responsibilities

• Run daily operations for assigned sites: staffing coverage, workload/meeting cadence, workload balancing, weekend/holiday coverage plan
• Develops, implements, and maintains formal and informal CDI education & training on clinical documentation and CDI software for a variety of disciplines, utilizing multiple approaches based on identified needs
• Reviews and validates CDI impact charts to confirm accuracy
• Provide real-time clinical review for tough cases (ICU acuity, procedures, cardiology/cardiac surgery, sepsis/resp failure, shock, encephalopathy, malnutrition, etc.) and escalate as appropriate to ensure there is appropriate SOI/ROM
• Review department data for quality and accuracy, identifying trends, systemic issues and factors contributing to inaccurate data impacting quality and patient safety
• Conducts educational programs related to documentation improvement opportunities, coding and reimbursement issues, as well as performance improvement methodologies for internal customers and physicians
• Analyzes and compiles accurate and complete data for statistical reporting and educational presentations, as needed
• Communicates and interacts with physicians and clinical staff via informal verbal communication, the use of written communication tools, and formal educational presentations
• Utilizes research, analytic data, and observations to provide recommendations to improve the overall quality and completeness of clinical documentation
• Collaborate with Quality reviewer to go over MHAC, PSI, PPC documentation risks
• Performs concurrent and retrospective reviews of the medical record (as needed), utilizing evidence-based knowledge, protocols, and criteria
• Facilitates modifications to support clinical documentation of health team members to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a focus on physician documentation, inpatients and DRG payers
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart
• Assisting and supporting leadership in planning, directing, and controlling all aspects of the day-to-day events in CDI department

Benefits

• Work life balance through nonrotating shifts
• Recognition and rewards for professional expertise
• Free Employee parking
• Medical, Prescription, Dental, and Vision coverage for employees and their eligible dependents effective on your date of hire
• Employer-paid Short & Long-Term Disability, Basic Life Insurance and AD&D, (short-term disability buy-up available)
• Paid Time Off
• Employer retirement contribution and match after 1-year of eligible employment with a 3-year vesting period
• Voluntary benefits include flexible spending accounts, legal plans, and life, pet, auto, home, long term care, and critical illness & accident insurance
• Subsidized childcare at participating childcare centers
• Tuition Reimbursement
• Employee Assistance Program (EAP) support

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Ph.D. or professional degree