Clinical Document Integrity Lead

Department
Revenue Cycle
Job Summary

The Clinical Documentation Integrity Lead is responsible for assisting and supporting leadership in planning, directing, and controlling all aspects of the day-to-day operations for the Clinical Documentation Integrity (CDI) program by establishing a collaborative rapport with CDI Specialists, department leadership, and providers (Physicians, Advanced Practice Professionals and Medical Residents). The Lead is also responsible for facilitating improvement in the overall quality, completeness, and accuracy of the medical record documentation through extensive audit investigation, education, and data analysis. Responsible for working with physicians, coders, ancillary department staff, CDI, and other allied health professionals to improve documentation of patient care and to appropriately assign codes and/or determine charges to support those services. Performs pre-bill compliance audits to ensure accurate code assignment, application of coding guidelines, and compliance with external regulatory and accreditation requirements. Identifies solutions to improve the overall data quality of the health records and to assure that appropriate reimbursement is obtained for services provided.

Required Qualifications

- Requires a minimum of four (4) years of experience as a Clinical Documentation Integrity Specialist.
- Require a Bachelor's (preferably BSN) degree in a relevant field; or an Associate of Science n Nursing (ASN) degree and two (2) years of relevant clinical work experience in an acute care inpatient setting can substitute for a required degree.
- Require an active Florida Registered Nurse (RN) license or Medical Doctor (MD) equivalent.
- Require Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) certification within one (1) year along with the maintaining of required Continuing Education Units (CEUs) thereafter.

Preferred Qualifications

- Prefer demonstrated proficiency in verbal and written communication.
- Prefer demonstrated ability to be a team player who is able to delegate and work in a team environment.
- Prefer demonstrated ability to work independently, shift priorities and demonstrate decision-making ability.
- Prefer demonstrated ability to meet tight deadlines and successfully handle multiple tasks at a time.
- Prefer demonstrated ability to remain calm and project a positive attitude and proactively engage physicians.
- Prefer coding skills with experience in ICD-10-CM and working knowledge of the AHA Coding Clinic.
- Prefer experience as a Clinical Documentation Integrity Auditor/Educator.