Lead CDI Specialist

Driscoll Health Plan; Austin (TX); On-site; USD 110,000 - 140,000; Full time

Job summary

Driscoll Health Plan seeks a Lead Clinical Documentation Department Improvement Specialist to oversee the CDI team, including licensed nurses and coders, ensuring accurate inpatient documentation and coding for APR-DRG reimbursement.

The role emphasizes leading reviews of complex pediatric cases, educating physicians and staff on MS-DRG/APR-DRG methodologies and collaborating with CDI Physician Champion and care teams to improve documentation quality and reporting.

Qualifications

• RHIA/RHIT/CCS/CDIP/CCDS preferred with 2+ years ICD hospital-based coding experience, or RN/LVN/BSN with 3+ years pediatrics/Med-Surg/ICU/Surgery.
• Strong communication skills; proficiency with Microsoft Outlook, Word, and Excel.

Responsibilities

• Acts as subject matter expert for CDI, inpatient coding, and reimbursement methodologies.
• Educates medical staff on MS-DRG and APR-DRG reimbursement processes.
• Oversees CDI reviews and coordinates with HIM management.
• Queries physicians to clarify documentation for accuracy and completeness.
• Monitors case mix patterns and trends to identify improvement opportunities.
• Maintains knowledge of payer regulations and reporting guidelines.
• Collaborates with CDI Physician Champion and care teams to optimize documentation.
• Prepares and presents monitoring/trending reports for review.

Skills

Leadership

Clinical Documentation

Query Management

Education & Training

Education

RHIA

RHIT

CCS

CDIP

CCDS

Tools

Epic

3M CRS

3M CDI 360 Encompass

Outlook

Word

Excel

Job description

Where compassion meets innovation and technology and our employees are family.

Thank you for your interest in joining our team! Please review the job information below.

General Purpose of Job:

The Lead Clinical Documentation Department Improvement Specialist is a certified coder with a high level of clinical proficiency necessary for leadership of the Clinical Documentation team of licensed nurses and certified coders. Oversees the review processes of complex pediatric patients in accordance with all current payer initiatives and development in acute and chronic disease states; understands a wide range of specialized disciplines, including education in anatomy and physiology, pathophysiology, and pharmacology; knowledge of official medical coding guidelines, CMS, and private payer regulations related to the Inpatient Prospective Payment System; an ability to analyze and interpret medical record documentation and formulate appropriate physician queries; and an ability to benchmark and assist in analyzing clinical documentation program performance. Exhibits a sufficient knowledge of clinical documentation, coding, reporting requirements, APR-DRG assignment, and clinical conditions or procedures impacting severity of illness, risk of mortality, and/or data quality.

Essential Duties and Responsibilities:

• Always maintains utmost level of confidentiality and integrity.
• Adheres to hospital policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
• Serves as a subject matter expert for the CDI program, inpatient coding, and reimbursement methodologies.
• Demonstrates ability to educate medical and hospital staff regarding the MS-DRG and APR-DRG reimbursement methodologies.
• Assists HIM management with coordination of CDI compliance reviews.
• Communicates with hospital personnel regarding questions relevant to CDI, inpatient coding, and reimbursement.
• Assists HIM management in communicating with physicians and other clinicians concerning opportunities for improvement relevant to clinical documentation and its impact on reporting.
• Assists HIM management in the development and maintenance of hospital specific CDI, reporting and billing guidelines.
• Attends hospital committee meetings as needed.
• Monitors and evaluates case mix patterns and trends.
• Reviews and codes inpatient medical records as needed for additional backlog and reporting support.
• Assists with special projects as assigned by HIM management.
• Must maintain current knowledge of reimbursement systems and federal, state and payer-specific regulations and policies.
• Must demonstrate continuing education in CDI, inpatient coding, and/or reporting compliance areas.
• Completes initial reviews timely in order to promptly identify potential documentation improvement opportunities.
• Conducts follow-up reviews of patients as scheduled to support and assign a working or final APR- DRG.
• Queries physicians regarding missing, unclear, or conflicting health record documentation.
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
• Collaborates with CDI Physician Champion, case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.
• Participates in the analysis and trending of statistical data for specified patient populations to identify documentation improvement opportunities.
• Assists with preparation and presentation of clinical documentation monitoring/trending reports for review.
• Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to assign ICD-9-CM and ICD-10-CM/PCS diagnosis and procedure codes to determine an accurate working and final APR-DRG, severity of illness, and/or risk of mortality.
• Assists in the appeal process resulting from third-party reviews.
• Proficiency in the use of Microsoft applications (e.g. Word, Excel, PowerPoint), Epic, and 3M CRS and 3M CDI 360 Encompass.

Education and/or Experience:

RHIA, RHIT, CCS, CDIP, or CCDS certification preferred with a minimum of two years ICD hospital-based coding experience or are clinical candidates minimally credentialed or above as RN, LVN or BSN with a strong clinical background and a minimum of three years clinical experience in Pediatrics, Med-Surg, ICU, or Surgery.Proficient in polished communication skills, Outlook, Word, and Excel.

Certificates, Licenses, Registrations.

RHIA, RHIT, or CCS certification preferred or eligible – to be achieved within 2 years of employment. CDIP or CCDS certification preferred or eligible – to be achieved within 3 years of employment.