Clinical Documentation Specialist Lead - REMOTE - Steward Health Care System

POSITION SUMMARY:

The Clinical Documentation Integrity Specialist (CDIS) Lead is an advanced level position for the experienced and proficient CDI Specialist consistently meeting or exceeding all criteria for CDIS III performance, with an additional emphasis on management responsibilities and expanded scope of oversight. The CDIS Lead provides support to the CDI Manager and leadership within a defined scope of facilities and CDI team. The CDIS Lead serves as a liaison between senior leadership, medical staff, nursing, coding, case management and quality departments. Excellent communication skills, interpersonal skills and the ability to identify, problem solve, and independently direct self and others is a key component of the CDIS Lead role. The role encompasses leadership and management responsibilities with a focus on career growth and development.

KEY RESPONSIBILITIES:

At the direction of the CDI Manager and CDI leadership:

May be assigned special projects related to CDI processes, quality, data analysis, or HIM/CDI performance
Assumes responsibility for daily workflow process and adjustments for the CDI team
May present CDI performance metrics at facility meetings
May report KRONOS time
Will assume operational oversight in the absence of the CDI Manager
Supports CDI team through multidisciplinary approach in support of program goals
Facilitates collaborative efforts between CDI, HIM and Medical Staff providers
Facilitates collaborative efforts between CDI and clinical teams such as Quality and Case Management
Effectively utilizes leadership abilities and critical thinking skills to identify opportunities for team process and engagement optimization
Maintains professional competency in documentation and coding practices by keeping up to date on new coding guidelines, policies/procedures, federal and state reimbursement.
All tasks must be performed in accordance with the established Steward CDI daily workflow with adherence to Inpatient CDI Handbook protocols.
Maintains confidentiality within the leadership team concerning all responsibilities described herein
Consistently communicates both verbally and in writing with CDI Manager, reporting potential and/or actual problems identified
May be requested to perform other related tasks, record reviews or responsibilities as assigned.
Performs all the above functions with minimal supervision and optimal accuracy and efficiency.
Promotes a positive, engaging and professional, culture supportive of Steward CDI Program goals and standards.
Actively supports Steward CDI program initiatives implemented by Steward Corporate leadership.



REQUIRED KNOWLEDGE & SKILLS:

Must possess strong organizational, communication, time management and clinical foundation skills.
Must demonstrate proficiency in EMR software, CDI applications (after education and orientation) and Microsoft applications.
Demonstrates ability to multi-task and work efficiently and effectively between software platforms.
Demonstrates the ability to communicate effectively in a fast-paced environment with multidisciplinary teams consisting of physicians, nurses, coders, administration and other health care professionals.
Ability to work independently, prioritize tasks and demonstrates self-awareness as to when to seek assistance.
Proven ability to maintain confidentiality and HIPAA compliance at all times.
Possesses the knowledge and ability to drive operational metrics
Participates in the education and onboarding process of all new hires
Participates in the daily operations of the team
Works in collaboration with the HIMDs/Coding managers to improve processes and performance

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:
I. Education: Bachelors degree in a clinical or coding study is preferred. Masters degree in a health care or related field is preferred.
II. Experience: Minimum of 2-5 years acute clinical or coding (IP) experience preferred. A minimum of 5 years CDI experience required. Management/leadership experience preferred.
III. Licensure: RN current State License
IV. Certification: CCDS or CDIP certification is required.
V. Software/Hardware: Proficiency in Microsoft applications, EMR applications, CDI and coding software

About Steward Health Care
Over a decade ago, Steward Health Care System emerged as a different kind of health care company designed to usher in a new era of wellness. One that provides our patients better, more proactive care at a sustainable cost, our providers unrivaled coordination of care, and our communities greater prosperity and stability.
As the country's largest physician-led, minority-owned, integrated health care system, our doctors can be certain that we share their interests and those of their patients. Together we are on a mission to revolutionize the way health care is delivered - creating healthier lives, thriving communities and a better world.

Based in Dallas, Steward currently operates more than 30 hospitals across Arizona, Arkansas, Florida, Louisiana, Massachusetts, Ohio, Pennsylvania, and Texas.

For more information, visit steward.org