Eligibility : Requires Illinois residency within 180 days of hire date.
Salary : Final salary offered will be determined by a thorough assessment of available market data, internal salary equity, candidate experience and qualifications, and budget constraints.
Position Summary
The Lead Clinical Documentation Specialist assists with the day-to-day oversight and reviews the progress of the Clinical Documentation Improvement program through interpretation of the CDI and quality rating reports under the leadership of the Clinical Documentation Improvement Director. The Lead CDI role leads, provides, and maintains clinical documentation improvement (CDI) practices to ensure consistency and meet coding rules, query compliance, and organization compliance guidelines. Works closely with the CDI Director, CDISs, Quality department, and the HIM department in the management of patient encounters that may include DRG optimization, assists with clinical denials, ensures that the quality measures (HACs and PSIs) are accurately captured, and assists with mortality reviews.
Duties & Responsibilities
Principal Responsibilities
Assists the Clinical Documentation Improvement Director with the daily oversight of the CDI team
Assists the CDI Director with tracking the CDI productivity metrics, performs quality reviews, captures areas for improvement, identifies educational needs, and prioritizes workload effectively
Performs case reviews, initiates queries, and conducts the reconciliation process as per CDI workflows
Strategizes approach and process refinements to capture opportunity within the CDI team (prioritization, assignment, etc.) based on retrospective and second-level reviews
Works collaboratively with Health Information Management (HIM), Coding, Quality, Case Management, and Compliance to ensure accurate documentation for appropriate reimbursement and quality reporting.
Assists the CDI Director in clinical denials management and identifies opportunities to reduce future denials
Serves as a subject matter expert in clinical data reporting and leads the overall quality and completeness of the clinical documentation improvement through the application of evidence-based knowledge, in-depth review, interpretation, analysis, and identification of opportunities, communication, and consistent follow-up and evaluation of medical record documentation.
Monitors internal CDI key indicator metrics related to revenue cycle, provider performance, and quality outcomes
Identifies opportunities for provider education to improve the medical record documentation for the overall accuracy of the medical record
Responsible for onboarding and ongoing competency development for the CDI team, and participates in CDI-related projects
In conjunction with the CDI Director, contributes to the development and training opportunities for the CDI staff and other duties as assigned
Collaborates directly with providers to clarify documentation to accurately and completely reflect the patient's medical conditions
Other duties as assigned
Perform other related duties and participate in special projects as assigned.
Minimum Qualifications
Licensure as a Registered Professional Nurse in Illinois.
Bachelor’s degree in nursing (BSN) or health related field.
Minimum of 4 years of acute care clinical nursing experience.
Minimum of 3 years of Clinical Documentation Improvement experience in the acute care setting.
Ability to interact with providers, leadership, and coworkers with tact, discretion, and diplomacy.
Demonstrates strong skills in oral and written communication, organized, and flexible.
Intermediate to advanced user of Microsoft Office Suite
Other Knowledge Base Skills
Knowledge of ICD-10-CM/PCS Guidelines in Coding and Reporting, CMS guidelines, and Quality measures
General knowledge and proficiency in CDI/encoder Software (3M/Solventum/Optum) and Epic EMR
Ability to analyze data and prepare PowerPoint presentations
Ability to prepare and analyze data to drive performance and priorities for improvement
Preferred Qualifications
Master’s degree in nursing (MSN) or another healthcare-related field
At least 2 years of supervisory/administrative experience in a health care field.
At least 2 yrs. of CDI educator, or CDI auditing experience.
To Apply
For fullest consideration click on the Apply Now button, please fully complete all sections of the online application including adding your full work history with specific details of your duties & responsibilities for each position held. Fully complete the education, licensure, certification and language sections. You may upload a resume, cover letter, certifications, licensures, transcripts and diplomas within the application.
Please note that once you have submitted your application you will not be able to make any changes. In order to revise your application you must withdraw and reapply. You will not be able to reapply after the posting close date. Please ensure the application is fully completed and all supporting documents have been uploaded before the posting close date.
The University of Illinois System is an equal opportunity employer, including but not limited to disability and/or veteran status, and complies with all applicable state and federal employment mandates. Please visit Required Employment Notices and Posters to view our non-discrimination statement and find additional information about required background checks, sexual harassment/misconduct disclosures, and employment eligibility review through E-Verify.
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