Ensures the work output of the Clinical Documentation Integrity staff is accurate and compliant. Educates individuals on the rules/regulations associated with coding and clinical documentation integrity Collaborates with Coding Analysts and Coding Manager, and assists with education of coding staff with regard to clinical documentation integrity and/or clinical scenarios as needed.
* Responsible for Quality Monitoring: Performs detailed analysis of cases handled by the CDI Specialists for quality control purposes, and provides constructive feedback to clinicians and CDI Specialists. (25%)
* Responsible for training of new CDI Specialists, providing feedback and tracking progression through the orientation period. (20%)
* Performs second level review prior to final coding of target case populations (no CC/MCC cases, mortality reviews, HAC's/PSI's, etc.). (20%)
* Ensures staff members are properly analyzing patient records for accuracy and specificity of diagnostic terminology, and resolves cases with physicians and/or medical staff that are escalated. (15%)
* Responsible for providing CDI Specialists, physicians and other clinical staff across UH with educational sessions about documentation improvement. (10%)
* Performs other duties as assigned. (5%)
*This role may encounter Protected Health Information (PHI) as part of regular responsibilities. UH employees must abide by all requirements to safely and securely maintain PHI for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.
* Bachelor's or Associate's Degree in Nursing or Health Information Management required.
Required Credentials, Licensure or Certification (i.e. RN, RRT):
* Certified Coding Specialist (CCS) , Registered Nurse (RN), Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) required.
***Must obtain and maintain CCDS certificate within 1 year of hire.***
Experience & Knowledge:
* 2 years Clinical Documentation Improvement experience required, preferably in an academic medical center.
* Coordinator, Supervisor or Educator experience preferred.
* Must have up-to-date clinical and coding experience, and current working knowledge of pathology, pharmacology, surgical procedures, etc.
* Must be detail-oriented and organized, have excellent time-management skills, and have good analytical and problem solving ability.
* Notable client service, communication, presentation and relationship building skills required.
* Ability to function independently and as a team player in a fast-paced, demanding work environment required.
* Ability to exercise independent judgment and maintain confidentiality required.
* Excellent written and verbal communication skills required.
* Experience working directly with physicians required.
Special Skills & Equipment Knowledge:
* Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e., printers, copy machine, FAX machine, etc.) required.
* Experience using clinical computer systems required.
Equal Opportunity Employer - minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity.