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GENERAL SUMMARY: Under general supervision of the CDI Manager following established policies, procedures and professional guidelines serves as a Lead CDI Specialist and second level reviewer for the department. The CDI Lead is an expert clinician who works in partnership with multidisciplinary teams, including but not limited to Coding, Quality, Infection Control and medical staff to improve the quality and accuracy of the medical record documentation. The CDI Lead monitors the accurate reporting of SOI/ ROM scores and MCC /CC capture rates for DRGs assigned. The CDI Lead maintains clinical and professional competencies for subject matter expertise in clinical documentation improvement concepts. They are responsible for concurrently reviewing inpatient medical records to identify vague, inconsistent or incomplete documentation within the medical record and assign the most appropriate medical severity diagnostic related group (MS-DRG). Further clarification of the principal and secondary diagnoses is carried out by collaborating with the physician(s) and/or care provider designees as appropriate. Participates in the educational and onboarding process of new team members. Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record. Ensures that all written requests to physicians for additional documentation support compliance and departmental policies. Demonstrates the ability to prioritize daily work activities, is self-directed and is able to complete daily work assignments with limited supervision. Performs quality screening for assigned patients for accurate assignment of a PSI and HAC to inpatient encounters. Assists with and analyzes outcome data relevant to the target case type to promote complete and accurate documentation. Analyzes and evaluates the effect of CDI on quality outcomes, fiscal parameters, and system operations and implements strategies to resolve system, performance and patient variances. Maintains and updates the CDI Dashboard to track CDI measures of success and benchmark department effectiveness. Serves as a liaison between the CDI team and the medical staff. Collaborates with physicians and appropriate healthcare providers regarding documentation requirements and trends, as needed. Provides classroom and one-on-one training for CDI staff including initial CDI process and concept training and ongoing education related to new topics in CDI, coding and reimbursement in conjunction with CDI Manager. Develops and provides formal and informal physician and staff education related to documentation improvement. Attends educational programs to enhance knowledge of clinical area served. Leads and/or participates on committees within the department, and TGH relevant to clinical documentation improvement. Assists in audits of CDI team as needed, makes appropriate recommendations for workflow improvement and accuracy as needed. Collaborates with Coding leadership and serves as a liaison between departments. Performs reconciliation of charts and differences in DRG assignments. Adheres to the Association of Clinical Documentation Improvement Code of Ethics and American Health Information Management Association’s code of ethics related to query process. Works with providers related to query responses, education and training. QUALIFICATIONS: RN, Bachelor's Degree. Certified Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS) or obtain and maintain certification within one year of employment. Greater than 5 years clinical experience and greater than 3 years experience as a Clinical Documentation Improvement Specialist. Preferred clinical experience with acute care experience at a large facility. Preferred experience with 3M360 Clinical Documentation and EPIC electronic medical record. Excellent communication and interpersonal skills; ability to communicate verbally and in writing with individuals of varying educational levels; credible with Physician leadership. Significant financial and analytical skills. Word, Outlook, Excel, PowerPoint experience preferred. Analytical skills necessary to clinically assess medical records required.

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