Remote - Clinical Documentation Specialist (CDI) Team lead

Job Family:

CDI Specialist

Travel Required:

None

Clearance Required:

None

What You Will Do:

The Clinical Documentation Integrity (CDI) Lead functions as a working CDI maintaining on-site/remote responsibility for implementation and supervision of the day-to-day operations of the Clinical Documentation Integrity team. The CDI Lead is the onsite/remote liaison for the CDI team and client. In addition, this position performs concurrent record reviews on assigned unit(s) at least 60% of time and performs administrative program duties (CDI team scheduling/floor coverage, productivity monitoring, monitoring key performance indicators (KPI’s), attend meetings, assist with second level reviews, etc.) 40% of time, and working directly with the Physician Advisors. This position will perform all related job duties as assigned.

Lead Duties (60% approximately 24 hours/Week)

• Oversee the daily review assignments for each CDI Specialist to ensure review workload is distributed evenly.
• Cover out of office staff assignments (i.e., closing out pending queries, re-reviews, DRG MM etc.)
• Monitors CDI productivity and project utilization monthly

• Serves as a subject matter expert in clinical data reporting and leads the improvement of the overall quality and completeness of clinical documentation through the application of evidence-based knowledge, analysis, in-depth review, interpretation, identification of opportunities, communication, and consistent follow-up and evaluation of concurrent and retrospective (as required) medical record documentation.
• Monitors internal key indicator metrics and develops corrective action plan when metrics not achieved.

• Performs analytical assessment of data, data manipulation, and professionally articulates data outcomes to improve operations and report to various committees, including but not limited to the monthly facility specific Utilization Review Committees and Chief Medical Officer.
• Performs monthly quality reviews and presents findings to the CDI Manager and Director
• Develop education for physicians and CDI staff as needed.
• Participates in interviewing, hiring, and onboarding of CDI specialists.

• Clearly communicate program updates, concerns or client requests that are out of scope to the Manager and Director of CDI
• Other duties assigned.

CDI Duties (40% approximately 16 hours/Week)

• Facilitates appropriate clinical documentation to support appropriate diagnosis and procedure coding.
• Collaborates with HIM coding staff to promote complete and accurate clinical documentation and correct negative trends.
• Communicates with physicians, case managers, coders, and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and severity of illness.
• Assigns a working DRG using official coding guidelines on initial and subsequent follow up reviews.
• Updated working DRG for Case Management team per facility specific process
• Queries providers on a concurrent (and as appropriate retrospective) basis. Collaborates with providers per facility policy to clarify documentation in the medical record.
• Formulate compliant and credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, procedures, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI’s). (Following ACDIS, AHIMA and CMS guidelines for effective and compliant query process.)
• Utilizes software system (including CDI and Encoder technology) to collect, track and report outcomes. Maintains integrity of data collection.

What You Will Need:

• Bachelors degree and 5 years of prior relevant experience
• Must have one or more of the following:  RHIA, RHIT, RN, MD, or CCS
• 5 years of inpatient coding
• 3 years of CDI experience
• Must maintain credential while employed.
• Maintain state of licensure CEU credits and provide copies of such upon hire and per state guidelines.

What Would Be Nice to Have:

• CCDS, CDIP
• Strong clinical understanding of disease process.
• Demonstrates critical thinking, analytical skills, and ability to resolve problems.
• Maintains current working knowledge of Official Coding Guidelines and Coding Clinics
• Strong knowledge of medical terminology, anatomy, physiology, microbiology, and disease processes
• Excellent communication skills, employing tact and effectiveness.
• Strong typing and computer skills; proficiency with EHR systems, DRG assignment and encoders
• Ability to work with Microsoft Office, Excel, and computer programs as well as company specific programs.
• Ability to conduct presentations to facility physicians and leadership.
• Prefer 5 years CDI experience OR inpatient clinical experience with 5 years clinical or case management or clinical management experience.

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The annual salary range for this position is $80,000.00-$133,000.00. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, experience and training, security clearances, licensure and certifications, and other business and organizational needs.

What We Offer:

Guidehouse offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.

Benefits include:

• Medical, Rx, Dental & Vision Insurance

• Personal and Family Sick Time & Company Paid Holidays

• Position may be eligible for a discretionary variable incentive bonus

• Parental Leave

• 401(k) Retirement Plan

• Basic Life & Supplemental Life

• Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts

• Short-Term & Long-Term Disability

• Tuition Reimbursement, Personal Development & Learning Opportunities

• Skills Development & Certifications

• Employee Referral Program

• Corporate Sponsored Events & Community Outreach

• Emergency Back-Up Childcare Program

About Guidehouse
Guidehouse is an Equal Employment Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, citizenship status, military status, protected veteran status, religion, creed, physical or mental disability, medical condition, marital status, sex, sexual orientation, gender, gender identity or expression, age, genetic information, or any other basis protected by law, ordinance, or regulation.

Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.

If you have visited our website for information about employment opportunities, or to apply for a position, and you require an accommodation, please contact Guidehouse Recruiting at 1-571-633-1711 or via email at RecruitingAccommodation@guidehouse.com. All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation.

Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee.

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