Lead Clinical Document Spec

Responsibilities

Incorporates the job functions of the Clinical Documentation Improvement Nurse with additional responsibilities of coordinating staff assignments, education, training, and supporting day-to-day CDI operations.

Supports the clinical severity of inpatient admission and quality documentation standards that align with federal and state regulations.

Affords assistance in maximizing revenue.

• Directly participates in CDI assignments, serving as a clinical resource.
• Conducts complex medical record reviews to identify documentation improvement opportunities (e.g., for PSI, VBP, HAC, readmissions, PDX clarification).
• Develops effective physician queries.
• Maintains query rates and assists with project initiatives to enhance workflows and reporting outcomes.
• Supports and monitors staff workflows, productivity, and quality.
• Works with management to develop and monitor performance indicators related to the revenue cycle and quality outcomes.
• Maintains high customer service standards and assists with staff education on documentation, ICD-10, and IPPS updates.
• Participates in continuous professional development.
• Facilitates leadership support by giving input on daily operations, co-planning evaluations, modeling organizational behaviors (URMC/ICARE), and fostering trusting relationships.
• Recognizes staff, rounds for outcomes, provides timely feedback, assists with scheduling and accountability, facilitates staff meetings, participates in hospital committees, drives change, and onboards new team members.
• Contributes to broader hospital and departmental goals by participating in data collection, fostering interdisciplinary collaboration with various departments (e.g., physicians, Quality, HIM, Denials Management), ensuring adherence to regulatory guidelines and internal policies, and acting as a liaison to resolve documentation discrepancies.
• Represents CDI perspectives in interdisciplinary meetings and participates in hospital projects.
• Works collaboratively to analyze and report metrics to service lines.
• Leads processes improvement initiatives for documentation refinement.

Qualifications

• Minimum Education & Experience: Bachelor's degree in Nursing (BSN) and 6 years of inpatient clinical experience, knowledge of complex disease processes, including 2 years of Clinical Documentation Improvement expertise in acute care required OR Bachelor's, Master's or Doctorate degree in a relevant clinical discipline: Prepared Physician Assistant (PA) or Nurse Practitioner (NP) or Bachelor of Medicine, Bachelor of Surgery (MBBS) or Doctor of Medicine/Osteopathic Medicine (MD/DO) and 6 years inpatient clinical experience, knowledge of complex disease processes, including 2 years of Clinical Documentation Improvement expertise in acute care required OR Equivalent combination of education and experience.
• Licenses And Certifications: Registered Nurse License, current in NYS upon hire required or NP – Nurse Practitioner license, current in NYS upon hire required or PA – Physician Assistant license current in NYS upon hire required or MD - Doctor of Medicine - MD License current in NYS upon hire required or DO - Doctor of Osteopathic Medicine current DO License in NYS upon hire required AND Clinical Documentation Specialist (CDS) upon hire required or CDIP - Clinical Documentation Improvement Professional upon hire required.