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Lead Clinical Documentation Improvement Specialist (40 hrs/days)(Temple Phy at Temple Health System
Philadelphia, Pennsylvania, United States -
Full Time

Start Date

Immediate

Expiry Date

26 Dec, 25

Salary

0.0

Posted On

27 Sep, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

No

Skills

Clinical Documentation, Medical Record Documentation, Disease Management, Patient Classification Systems, Education Programs, Quality Reviews, ICD-10 Coding, Documentation Improvement, Communication, Clinical Staff Education, Quality Metrics Reporting, Inpatient Medical Setting, Patient Care, Severity of Illness, Risk of Mortality, Diagnostic Related Groups

Industry

Hospitals and Health Care

Description
Serves as the primary resource to the Clinical Documentation Specialists on all aspects of medical record documentation required to support the accurate classification of patient's severity of illness/medical complexity. Possess extensive knowledge of both clinical medicine and disease management, as well as the internal and external patient classification systems that measure patient's severity of illness and medical complexity. The CDI lead along with the CDI manager will be the primary educator for the clinical staff. Responsible for clarifying documentation regarding quality-of-care issues. The CDI lead is responsible for the daily review of current inpatient medical records, abstracts pertinent clinical information and translates the clinical information into a hospital-based coding system utilizing ICD-10. Identifies opportunities for documentation improvement to support accurate assignment of diagnostic related groups (DRGs), severity of illness (SOI) assignment, risk of mortality (ROM) assignment, and correct reporting of quality metrics. Communicates with the clinical staff through a variety of means to educate the staff and obtain clarification of documentation. Performs quality reviews and reports outcome to CDI manager and CDI Director. Develops education programs for the CDIS staff. Education Bachelor's Degree in a health-related field Required Experience 2 years experience in Patient care or Coding (inpatient medical setting) Required Licenses Certified Coding Specialist Preferred or PA Registered Nurse License Preferred
Responsibilities
The Lead Clinical Documentation Improvement Specialist serves as the primary resource for Clinical Documentation Specialists, focusing on accurate medical record documentation and classification of patient severity. Responsibilities include daily reviews of inpatient medical records, clarifying documentation, and developing education programs for staff.