Assess professional practice gaps, identify educational needs, provide feedback with solutions, and assist with the implementation and evaluation of strategies.
Identify and resolve conflicts of interest, maintain content integrity.
Evaluate data to guide future projects.
Function as a content expert as appropriate.
Communicate effectively with stakeholders across departments to achieve the best outcomes for the program.
Responsibilities:
- Maintain knowledge of all federal, state, and local documentation guidelines and communicate changes to all CDI staff; possess extensive knowledge of ICD-10 and coding guidelines.
- Collaborate with the Chief of CDI to develop, coach, train, and mentor CDI specialists and clinical staff to improve documentation practices.
- Handle stress appropriately and interact professionally with others.
- Perform clinical audits of clients and initial reviews of facilities, providing insights into findings.
- Develop and monitor the implementation of departmental goals and objectives.
- Assist in developing and implementing CDI strategies tailored to client needs and organizational goals.
- Serve as a subject matter expert, advising clients and internal stakeholders on best practices in clinical documentation.
- Ensure documentation compliance with regulatory requirements, including ICD-10, DRG, and other coding standards.
- Use summative evaluation data to guide future projects.
- Identify operational workflow gaps and recommend process redesigns.
- Perform other duties as assigned.
Qualifications:
- Excellent communication skills, both oral and written, with the ability to manage and prioritize multiple projects.
- Strong interpersonal and organizational skills.
- Proficient in Microsoft Office applications.
- Ability to present to management, staff, and business partners effectively.
- Comfortable working in a complex and evolving healthcare environment.
- Broad knowledge of healthcare regulations, including CMS, ICD-10, and DRG optimization, along with applicable reporting standards.
- Effective team collaboration with diverse disciplines and backgrounds.
- Apply critical thinking and strong organizational skills.
- Experience with risk adjustment and value-based care models.
Education and Experience:
- Nursing Degree (RN, BS, BSN, or higher).
- At least five years of clinical experience in acute care.
- Experience in Clinical Documentation Improvement (Acute Care).
- Proficiency with Microsoft Office (Excel, PowerPoint, Word).
- Minimum of 4 years CDI experience.
- Second-level review experience in CDI is highly preferred.
Licensure, Certification, or Registration:
- Current valid multi-state license as a Registered Nurse.
- Certified Clinical Documentation Specialist (CCDS), CCDS-O, or CDIP.
- Master’s degree in a healthcare-related field (MSN, MHA, MBA) is strongly preferred.
- Additional certifications such as CPC, CRC, CCS are preferred.