Job DescriptionDescriptionA Brief OverviewApplies clinical expertise and knowledge of health care workflows in order to educate and train CDI Specialists in the essential duties of their role to improve the overall accuracy and comprehensiveness of medical record documentation, with focus on ensuring accurate reporting of quality outcomes Educates CDI Specialists on the rules / regulations associated with coding and clinical documentation integrity.Trains newly hired CDI Specialists and provides ongoing coaching and education specific to daily CDI Specialist job functions.Ensures the work output of the Clinical Documentation Integrity staff is accurate and compliant.Collaborates with CDI leadership and Coding team to identify training opportunities and assist with education of CDI and Coding staff with regard to clinical documentation integrity and / or clinical and coding scenarios as needed.What You Will DoPerforms post-discharge, final coded, pre-bill reviews of targeted records identified for second-level review for opportunity to accurately capture patient acuity, severity of illness, risk of mortality, and DRG assignment in compliance with industry rules and regulationsDocuments SLR findings within CDI application.If a documentation opportunity is identified, place physician query and follow up for response to ensure completeness and accuracy of the medical record.If coding opportunity is identified, coordinate with coder and / or Coding Leadership to review and address opportunity as applicableServes as a role model and resource for CDI team membersSubject matter expert that exhibits excellent skills in essential components of the CDI Specialist roleResponds to CDS requests for concurrent chart reviews on challenging cases with recommendations and supporting rationalePerforms concurrent second level reviews based on defined criteria and shares feedback with CDI Specialist assigned to the encounter for action on opportunities identified.Maintains a summary of opportunities identified through second level review for feedback and education with the CDI teamCoordinates with other Second Level Reviewers, CDI Leads, and CDI Educator to compile trends and areas of opportunity and conduct education both 1 :1 and group education with the CDI team based on the findingsPeriodically review the criteria established for cases triggering a second level review and recommend updates or modifications to the criteria to assist in identifying areas of opportunityIs actively engaged in quality and process improvement effortsPerforms targeted audits as assigned in support of department initiativesParticipates in quality initiatives such as HAC / PSI and US News / MortalityCollaborates with CDI Leadership, Leads and Educators to optimize query templatesIdentifies and shares feedback regarding workflow improvement opportunities identified when completing the SLR processFacilitates change and supports the CDI team through change management processesActively engages in advancing the CDI practice throughout the UH enterpriseActively engages in department and / or enterprise-wide committeeAdditional ResponsibilitiesPerforms other duties as assigned.Complies with all policies and standards.For specific duties and responsibilities, refer to documentation provided by the department during orientation.Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients.Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.QualificationsEducationOther Accredited Program :Diploma in Nursing or in Health Information Management (Required) orAssociate's Degree preferably in Health Information Management or Nursing (Required) orBachelor's Degree preferably in Health Information Management or Nursing (Required) orDoctorate Degree in Medicine (Required)Work Experience3years CDI experience as a concurrent reviewer (Required)Knowledge, Skills, & AbilitiesExtensive clinical knowledge and understanding of pathology / physiology; best demonstrated by clinical experience in hospital setting (Required proficiency)Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues (Required proficiency)Demonstrates comprehension of Case Mix Index (CMI) and can interpret, analyze, evaluate data, provide rationale for trends / impacting factors and develop strategy for correcting / optimizing CMI (Required proficiency)Knowledge of age-specific patient needs and the elements of disease processes and related procedures (Required proficiency)Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers (Required proficiency)Assertive personality traits to facilitate ongoing physician communication (Required proficiency)Working knowledge of inpatient admission criteria.(Required proficiency)Ability to work independently in a time-oriented environment as well as working as part of a team, primarily in a virtual setting.(Required proficiency)Applies knowledge and expertise to daily job responsibilities.Maintains professional knowledge by reading and / or attending webinars that pertain to Clinical Documentation Improvement.(Required proficiency)Earns and maintains Certification for Clinical Documentation Improvement.(Required proficiency)Incorporates current literature, research and best practice ( ACDIS and AHIMA ) into daily practice.(Required proficiency)Up to-date clinical and coding experience, and current working knowledge of pathology, pharmacology, surgical procedures, etc.(Required proficiency)Detail-oriented and organized, have excellent time-management skills, and have good analytical and problem-solving ability.(Required proficiency)Notable client service, communication, presentation and relationship building skills.(Required proficiency)Licenses and CertificationsRegistered Nurse (RN), Ohio and / or Multi State Compact License (Required Upon Hire) orRegistered Health Information Administration (RHIA) (Required Upon Hire) orRegistered Health Information Technologist (RHIT) (Required Upon Hire)Certified Clinical Documentation Specialist (CCDS) (Required Upon Hire) orClinical Documentation Improvement Practitioner (CDIP) (Required Upon Hire)International medical doctor education and experience can meet qualifications in lieu of RN, RHIA or RHITPhysical DemandsStanding OccasionallyWalking OccasionallySitting ConstantlyLifting Rarely up to 20 lbsCarrying Rarely up to 20 lbsPushing Rarely up to 20 lbsPulling Rarely up to 20 lbsClimbing Rarely up to 20 lbsBalancing RarelyStooping RarelyKneeling RarelyCrouching RarelyCrawling RarelyReaching RarelyHandling OccasionallyGrasping OccasionallyFeeling RarelyTalking ConstantlyHearing ConstantlyRepetitive Motions FrequentlyEye / Hand / Foot Coordination Frequently. Experience: 5 years required