Lead Clinical Documentation Specialist - Utilization Management

UR Thompson Health; Town of Canandaigua (NY); Remote; USD 55,000 - 66,000; Full time

Benefits offered by this job

Tuition assistance

Free parking

Competitive pay

Job summary

UR Medicine Thompson Health is seeking a Lead Clinical Documentation Specialist to supervise CDI activities in a remote setting with onsite orientation as needed. The role emphasizes documenting high-acuity cases, guiding physicians on compliant queries, and driving performance across the CDI program.

The successful candidate will have RN licensure with significant inpatient CDI experience, CDS/CDIP certification within two years, and leadership ability to train and mentor staff.

Qualifications

• Licensed RN with minimum of 5 years inpatient clinical experience.
• CDS or CDIP certification required within two years of starting the role.
• AAS required.
• BSN preferred or willingness to complete within 5 years of hire.
• Leadership experience in CDI context preferred.

Responsibilities

• Perform extensive medical record review using CDI software integrated with the EMR.
• Facilitate CDI enhancements through concurrent and retrospective physician and team interactions to support compliant documentation and revenue.
• Lead the CDI team and coordinate improvement practices with compliance and reimbursement considerations.
• Oversee training for providers, nurses and CDI staff.
• Participate in meetings to develop CDI program improvements and education.

Skills

Advanced clinical knowledge

Expert in coding and reimbursement

Leadership experience

Data analysis

Education

AAS required

BSN preferred

Tools

CDI software

EMR systems

Microsoft Office

Job description

Are you looking to make a real difference in the lives of others in an empowering and supportive work environment? Join our growing and well-respected community health system and enjoy competitive pay, high patient and staff satisfaction levels, free parking, tuition assistance and other excellent benefits! Join Thompson in this new role of lead clinical documentation specialist!

This position is remote with potential for occasional onsite meeting requirements. Hospital orientation is also required in person.

Main Function

• Performs extensive medical record review through the use of CDI software integrated with the EMR.
• Facilitates clinical documentation improvement through concurrent and retrospective interaction with physicians and members of the healthcare team. This interaction supports the clinical severity of the inpatient admission, quality documentation standards that align with federal and state regulations and assists with maximizing revenue and risk stratification.
• Act as the lead for the CDI team and assist with coordination of clinical documentation improvement practices consistent with corporate compliance guidelines and appropriate financial reimbursement based on the acuity of the patient population.
• Oversee training and education for providers, nurses and other CDI staff.
• Actively participate in team and committee meetings to assist with the development of improvement efforts and education regarding the Clinical Documentation Management Program (CDMP)

Required Job Specific Competencies

• Advanced Clinical Knowledge: including comprehensive understanding of anatomy, physiology, and disease processes
• Expertise in coding and reimbursement methodologies
• Clinical documentation principles: a strong grasp of compliant clinical documentation practices
• Effective physician querying: ability to formulate clear, concise and non-leading queries to physicians and other providers
• Auditing and Quality Assurance: proficiency in conducting retrospective and concurrent review of medical records
• Data Analysis and Reporting: ability to analyze CDI program date, identify trends in documentation and measure program effectiveness
• Education and training development: skill in developing and delivering targeted education and training programs for physicians, advanced practice providers, residents, and other healthcare staff on documentation best practices
• Leadership and mentorship: ability to lead a team of CDI specialists, provide guidance, mentorship and constructive feedback. Foster a collaborative and high-performing work environment
• Technology proficiency: competence in utilizing electronic health record systems, CDI software and other relevant healthcare information technology
• Adherence to all relevant health care regulations and hospital policies related to patient privacy (HIPAA), documentation, and billing

Qualifications

• Licensed RN with minimum of 5 years inpatient clinical experience and extensive knowledge of complex disease processes.
• CDS (Clinical Documentation Specialist) or CDIP (Clinical Documentation Improvement Practitioner certification required within two years of starting the role.

Education

• AAS required
• BSN preferred or willingness to complete within 5 years of hire

Experience

• Minimum 3-5 years CDI experience
• Leadership experience preferred
• Advanced clinical experience with extensive knowledge of complex disease processes preferred
• Proficiency with computers, spreadsheets and Microsoft office
• Position Pay Range: $40.00-48.00/hour
• Starting Pay: Based on experience

UR Medicine Thompson Health is an EOE encouraging individuals with disabilities and veterans to apply.