Health Information Management - Clinical Documentation Improvement Specialist Team Leader

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Summary:

• The Clinical Documentation Improvement (CDI) Specialist-Team Leader supports an organization-wide system for improving Clinical Documentation in the medical record by prompting physicians and other clinicians for complete and accurate documentation. The CDI Team Leader utilizes presentation, general instruction, and a compliant query discussion to instruct the clinical teams in appropriate documentation as suggested by CMS coding guidelines and to ensure that the clinical chart is the true and reflective document of the patient, their related prioritized diagnostic portrait, severity of illness, and treatment related.
  Working under the leadership of the Corporate Manager of Clinical Documentation and in close concert with both the clinical care teams and the Corporate HIM teams, the CDI Team Leader educates and utilizes compliant questions and tools towards a complete, reflective record. The Team Leader also analyzes trends and offers direction to primary care staff with regard to changes in coding practices and noted trends noted in team documentation requiring clarity and/or specification to reflect truth in diagnostic reflection. The Team Leader is also responsible for daily organization of team assignment, basic instruction/redirection of entity-based staff (under agreement of the CDI Manager), acts as a liaison between the Quality Analyst, CDI Manager, and HIM coding team for discovered questions and/or possible discrepancies and reiteration of new pathways and learnings instituted via CDI Management.

Responsibilities:

• Direct review of patient charts to audit clarity and full reflection of severity in care team documentation with consideration of CMS coding guidelines.
• Provide clinical care teams with ongoing education and training on current trends in documentation and coding.
• Participate as a management liaison/representative in entity-based staff meetings, MD and staff-focused formal presentations/discussions, daily team instruction, assignment and reinforcement of CDI goals and avenues of workflow, identification and discovery of new opportunity and/or adapted direction until which time the manager is required/available to intercede/participate.
• Collaborate with the Corporate Management of Clinical Documentation Improvement to develop/upkeep efficiencies/synergies within the CDI department. Assist with staff evaluations under the direction of the CDI Manager.
• Demonstrate as an expert level Clinical Data Specialist with regard to review of charts, truth and precision in documentation expectation and guidance of such towards proper coding, DRG assignment, and POA (present on admission) as presenting a clear, true clinical portrait of patient diagnosis and treatment. Ensure that the concurrent inpatient Clinical Documentation accurately reflects severity of illness and intensity of service using the above noted compliant query system. Perform concurrent and retrospective audits to guide/lead the team to the same via ongoing instruction and feedback.
• Act as management representative towards daily team assignment, entity-based meetings and discussions, daily reiteration of CDI team goals and workflows including teachings and adaptations. Takes the lead in clinical staff educational endeavors under the direct supervision of CDI Program Managers. Participates on departmental and hospital committees and taskforces, as assigned.
• Orient new CDS staff with regard to quality chart review methods, compliant query composition, timely follow-up and discussion, and handling of queries from initial review through to close, as well as, overall department expectations and workflow.
• Complies with UPHS policies on patient confidentiality including HIPAA requirements, Code of Conduct and Standards of Behavior.

Credentials:

• PA or NJ RN license required (depending on work location) (Required)
• CCS, CCDS, CDIP, RHIA or RHIT

Education or Equivalent Experience:

• Bachelor's degree in Nursing, Health Information Management, or other health care related field of study. (Required)
• 6+ years of clinical experience. (Required)
• Extensive knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems. (Required)
• Extensive clinical knowledge in reference to diagnosis, related clinical validation, and treatment considerations. (Required)
• Working knowledge of Medicare Reimbursement system and coding structures. (Preferred)
• Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation and coding. (Preferred)

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.
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We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.