Ld Clinical Doc Spclst

Summary:

Under general supervision of Manager of Clinical Documentation, the Lead Clinical Documentation Specialist is responsible for concurrent auditing of medical record documentation to assist with evaluating and improving the quality of clinical documentation of services to accurately reflect severity of illness, expected risk of mortality, and complexity of care of the patient.

The Lead Clinical Documentation Specialist, in collaboration with the CDI educator is responsible for the orientation of new staff, identification of process improvements, development of education material for CDI, coding staff and the provider community. The Lead CDI Specialist will have an integral role in the updating and implementation of the department's IS systems. The Lead CDI Specialist is seen as an expert in CDI with advanced knowledge of clinical documentation issues as they relate to proper assignment of ICD 10 CM and PCS codes and MS-DRG/APR DRG assignment, Coding Clinics, and broad scope of knowledge in Nursing and Medical disease, conditions, and pathology. 

Responsibilities:

Takes lead role in on boarding and precepting new staff. Identifies opportunities for education for less experienced staff and the department.

Assists as directed with review and response to commercial and governmental audits as needed.

Accurately performs concurrent and retrospective HAC/PSI, or Mortality reviews utilizing risk adjusted methodology and AHRQ specifications serving as a role model and departmental resource for this.

Active member of HAC/PSI committee providing reviews of specified cases while identifying educational needs and query challenges.

Oversees staff education on review of Mortality and HAC/PSI reviews. Has knowledge of up-to-date risk adjustment diagnoses. Identifies documentation and coding improvements to improve capture of risk adjustment diagnoses and develops education for CDI and coding staff.

Assists in individual providers or departments audits and develops and presents education to improve the quality of documentation.

Able to provide educational feedback to CDI management on audit risks, audit patterns of educational needs, and individual staff educational needs.

Has Ability to manage all CDI work ques to ensure efficient review of cases.

Demonstrates expert technical ability with 3M 360, Life Chart as well as other programs. Can perform in lead role for technical testing for system upgrades and implementation of new systems and will bring back to management areas of needed workflow change. Assist with testing. Can independently work with the IS team to resolve areas of technical concern.

Assists with development and revision of internal policies and procedures per management directive.

Identifies and develops Query templates needed by CDI department.

Keeps abreast of new coding guidelines, coding clinics and clinical developments that affect documentation and coding. Collaborates with CDI educator for CDI and coding staff educational needs.

Identifies, develops and presents information that will improve documentation and accurate coding to the CDI, coding staff and provider community.

Ability to perform standard CDI reviews according to productivity expectations of this role. Productivity standards in this role are 20 - 24 reviews per day which include the review of more complex cases.

Performs other duties as assigned.

Other information:

Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.

QUALIFICATIONS:

Registered nurse with current licensure to practice in the State of Rhode Island with 5 years of clinical documentation experience (BSN required, master's degree preferred), or

Physician assistant or nurse practitioner with current licensure to practice in the State of Rhode Island with 5 years of clinical documentation experience, or

Successful completion of education required for a medical degree with 5 years of clinical documentation experience

Certification in clinical documentation integrity from the Association of Clinical Documentation Integrity Specialists (ACDIS) or the American Health Information Management Association (AHIMA) required

SUPERVISORY RESPONSIBILITY:

None. General oversight of Clinical Documentation Specialists and Sr Clinical Documentation Specialists.

Brown University Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, ethnicity, sexual orientation, ancestry, genetics, gender identity or expression, disability, protected veteran, or marital status. Brown University Health is a VEVRAA Federal Contractor.

Location: Brown University Health Corporate Services, USA:RI:Providence

Work Type: Full Time

Shift: Shift 1

Union: Non-Union