Clinical Documentation Improvement Lead, Day Shift
2 weeks ago
Support Center
Adventist Healthcare seeks to hire an experienced Clinical Documentation Improvement Lead for our Support Center who will embrace our mission to extend God’s care through the ministry of physical, mental, and spiritual healing.
As a Clinical Documentation Improvement Lead, you will:
- Develops, implements, and maintains formal and informal CDI education & training on clinical documentation and CDI software for a variety of disciplines, utilizing multiple approaches based on identified needs
- Review department data for quality and accuracy, identifying trends, systemic issues, and factors contributing to inaccurate data impacting quality and patient safety
- Perform monthly department compliance audits and report on key performance indicators to include -PPC/HACS-PSI 90/Mortality Reviews
educational programs related to documentation improvement opportunities, coding, and reimbursement issues, as well as performance improvement methodologies for internal customers and physicians.
- Analyzes and compiles accurate and complete data for statistical reporting and educational presentations, as needed.
- Communicates and interacts with physicians and clinical staff via informal verbal communication, the use of written communication tools, and formal educational presentations.
- Utilizes research, analytic data, and observations to provide recommendations to improve the overall quality and completeness of clinical documentation.
- Analyzes, summarizes, and documents outcomes of the documentation improvement process for re-evaluation of ongoing program revisions. -Participates as a member of work groups related to clinical documentation, utilization, and compliance, if required.
- Establishes cooperative and multidisciplinary relationships with physicians, coding staff, and other health team members.
- Acts as a resource to the CDI department and health team members related to optimal documentation, educational needs, and successful problem resolution.
- Familiarity with APR-DRG’s and Inpatient Prospective Payment System (IPPS), including new CMS guidelines of key elements including clinical documentation of what constitutes an inpatient admission.
- Along with familiarity and the ability to effectively communicate the use of various coding systems and Official Coding Guidelines.
- Performs concurrent and retrospective reviews of the medical record (as needed), utilizing evidence-based knowledge, protocols, and criteria.
- Facilitates modifications to support clinical documentation of health team members to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a focus on physician documentation, inpatients, and DRG payers.
- Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
- Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
- Maintains and enhances current medical, coding, and CDI knowledge via participating in continuing education offerings.
- Effective ability to communicate the benefits of complete and accurate documentation to physicians relating to their daily practice of medicine.
- Performs audits on physician documentation, using the template provided by the HIM committee, on both initial and concurrent documents.
- Participates in second-level MHAC reviews and attends MHAC steering committee meetings monthly
Qualifications include:
Registered Nurse
- 5 years of patient care in a hospital setting.
- 3-5 years of CDI experience
- Verified current Maryland or other compact state RN license
- Active American Heart Association Basic Life Support (BLS) certification required
Work Schedule:
Monday through Friday 8 am to 4 pm
GR8 Other
At Adventist HealthCare our job is to care for you.
We do this by offering:
- Work life balance through nonrotating shifts- Recognition and rewards for professional expertise- 403(b) retirement plan- Free Employee parking- Benefits Eligible Positions:
- Competitive, comprehensive benefit plans [including health, employer-paid disability and life insurance, PTO]-
- Employer retirement contribution and match after 1-year of eligible employment with 3 year vesting-
- Ancillary benefits such as flexible spending, legal and pet insurance to meet the needs of employees and their eligible family members-
- Subsidized childcare at participating childcare centersAs a faith-based organization, with over a century of caring for the communities in the Maryland area, Adventist HealthCare has earned a reputation for high-quality, compassionate care. Adventist HealthCare was the first and is the largest healthcare provider in Montgomery County.
If you want to make a difference in someone’s life every day, consider a position with a team of professionals who are doing just that, making a difference.
COVID-19 Vaccination
Adventist HealthCare requires all appli
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