Lead CDI Specialist

General Purpose of Job

The Lead Clinical Documentation Department Improvement Specialist is a certified coder with a high level of clinical proficiency necessary for leadership of the Clinical Documentation team of licensed nurses and certified coders. Oversees the review processes of complex pediatric patients in accordance with all current payer initiatives and development in acute and chronic disease states; understands a wide range of specialized disciplines, including education in anatomy and physiology, pathophysiology, and pharmacology; knowledge of official medical coding guidelines, CMS, and private payer regulations related to the Inpatient Prospective Payment System; an ability to analyze and interpret medical record documentation and formulate appropriate physician queries; and an ability to benchmark and assist in analyzing clinical documentation program performance.

Essential Duties and Responsibilities

• Maintains utmost level of confidentiality and integrity.
• Adheres to hospital policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
• Serves as a subject matter expert for the CDI program, inpatient coding, and reimbursement methodologies.
• Demonstrates ability to educate medical and hospital staff regarding the MS-DRG and APR-DRG reimbursement methodologies.
• Affords assistance to HIM management with coordination of CDI compliance reviews.
• Communicates with hospital personnel regarding questions relevant to CDI, inpatient coding, and reimbursement.
• Affords assistance to HIM management in the communication with physicians and other clinicians concerning opportunities for improvement relevant to clinical documentation and its impact on reporting.
• Affords assistance to HIM management in the development and maintenance of hospital specific CDI, reporting and billing guidelines.
• Attends hospital committee meetings as needed.
• Monitors and evaluates case mix patterns and trends.
• Reviews and codes inpatient medical records as needed for additional backlog and reporting support.
• Affords assistance with special projects as assigned by HIM management.
• Maintains current knowledge of reimbursement systems and federal, state and payer-specific regulations and policies.
• Demonstrates continuing education in CDI, inpatient coding, and/or reporting compliance areas.
• Completes initial reviews timely in order to promptly identify potential documentation improvement opportunities.
• Conducts follow-up reviews of patients as scheduled to support and assign a working or final APR-DRG.
• Queries physicians regarding missing, unclear, or conflicting health record documentation.
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
• Collaborates with CDI Physician Champion, case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.
• Participates in the analysis and trending of statistical data for specified patient populations to identify documentation improvement opportunities.
• Affords assistance in the preparation and presentation of clinical documentation monitoring/trending reports for review.
• Affords assistance in ensuring accuracy of diagnostic and procedural data and completeness of supporting documentation to assign ICD-9-CM and ICD-10-CM/PCS diagnosis and procedure codes to determine an accurate working and final APR-DRG, severity of illness, and/or risk of mortality.
• Affords assistance in the appeal process resulting from third-party reviews.
• Proficiency in the use of Microsoft applications (e.g. Word, Excel, PowerPoint), Epic, and 3M CRS and 3M CDI 360 Encompass.