Beacon Health System-posted 2 months ago
Granger, IN
5,001-10,000 employees
Religious, Grantmaking, Civic, Professional, and Similar Organizations

Develops, implements, and has oversight over the Clinical Documentation Integrity (CDI) audit plan, utilizing audit findings to develop, implement, and maintain formal and informal training to physicians, mid-level providers and ancillary staff. Oversees and develops the audit plan and schedule for CDI department, including performing concurrent and retrospective reviews of the medical records, utilizing evidence-based knowledge, protocols, and documentation criteria. Develops formal and informal training and education material related to findings from audits and staff feedback; implements and facilitates this training with CDI staff, physicians, clinical and ancillary staff to improve the overall quality and completeness of clinical documentation. Assists Health Information Management leadership in developing meaningful goals, metrics and targets representing CDI's work performance and provider documentation performance. Assists leadership in the development of the CDI plan as it relates to quality metrics and provider education. Responsible for education of newly hired CDI staff, setting up orientation process, monitoring of orientee throughout orientation and reporting to leadership meeting of milestones and successes. Establishes relationships with physicians, other health team members and the coding team in order to communicate the benefits of complete and accurate documentation.

  • Develops and implements the Clinical Documentation Integrity (CDI) audit plan.
  • Performs concurrent and retrospective reviews of medical records.
  • Develops training and education material based on audit findings.
  • Facilitates training for CDI staff, physicians, and ancillary staff.
  • Assists in developing goals and metrics for CDI performance.
  • Educates newly hired CDI staff and monitors their orientation.
  • Establishes relationships with physicians and health team members.
  • Completion of a nursing program from an accredited school of nursing.
  • Current license to practice as a Registered Nurse in Indiana.
  • Minimum of five years of clinical experience in an acute care setting.
  • Recent critical care or strong medical/surgical background preferred.
  • Ability to pass a written clinical competency exam.
  • Demonstrated knowledge of age-specific needs and disease processes.
  • Advanced analytical and critical thinking skills.
  • Proficiency in computer systems and applications.
  • Maintains license/certification in good standing.
  • Completes mandatory education and annual competencies.
  • Adheres to regulatory agency requirements.
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