System CDI Quality Team Leader Educator

AdventHealth • Altamonte Springs, FL

117d

About The Position

Under general supervision of the Clinical Documentation Integrity (CDI) Manager, and in some situations the supervision of the Director of Clinical Documentation Integrity, and in collaboration with physicians, nursing and HIM coders, the CDI Quality & Compliance Team Leader strategically facilitates and obtains appropriate and quality physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The Quality Auditor Manager adheres to strict departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

Requirements

• Minimum of five (5) years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
• Two (2) years of Clinical Documentation Specialist experience.
• Current active State license as a Registered Nurse, Nurse Practitioner, or Physician's Assistant.
• CCDS (Certified Clinical Documentation Specialist) certification.
• CDIP (Certified Documentation Improvement Practitioner) certification.

Nice To Haves

• Bachelor's Degree BSN.
• Master's Degree MSN.
• PROSCI Certification.

Responsibilities

• Completes accurate and timely record review to ensure the integrity of clarification compliance for all CDSs throughout all facilities on a quarterly basis through audit process.
• Completes accurate and concise input of audits to provide feedback to CDI Market Leaders.
• Performs quality reviews of the medical record for compliance including completeness and accuracy for severity of illness (SOI) and quality performance measures.
• Understands and supports documentation strategies and continues to educate self and team members using educational tools, videos and provided WebEx's.
• Recognizes opportunities for documentation improvement using strong critical-thinking skills.
• Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs and HACs to ensure documentation compliance is accomplished.
• Strategically educates members of the patient-care team regarding documentation regulations and guidelines.
• Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation.
• Communicates with HIM staff and collaborates with them to resolve discrepancies with DRG assignments and other coding issues.
• Leads out on CDI projects as project manager, strategically planning and implementing the project through completion working collaboratively with the needed interdisciplinary departments.
• Participates in meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified by the CDI group.
• Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.
• Performs other duties as assigned.

Benefits

• Benefits from Day One
• Career Development
• Whole Person Wellbeing Resources
• Mental Health Resources and Support

What This Job Offers

• Job Type: Full-time
• Industry: Hospitals
• Education Level: Bachelor's degree