What are the responsibilities and job description for the Lead Clinical Documentation | Health Info & Record Management | Exempt position at UF Health?
This position is responsible for ongoing quality review and assessment of inpatient hospital charts. Performs audits on the accuracy of clinical reviews and physician queries. Performs review of claims denied for coding, documentation, and clinical validation, and formulates and submits letters of appeal. Prepares reports for management review and identifies trends. Conducts focused retrospective audits and regular scheduled audits of individual clinical documentation improvement specialists. Manages all audits conducted by internal and external entities and responds to requests for code verification. In conjunction with the Clinical Documentation Integrity Manager, contributes to the development of educational and training opportunities for staff.
Responsibilities
1.) Contributes to the accuracy of CDI functions by performing quality reviews.
- Performs reviews for all categories of records coded at least quarterly.
- Performs quality reviews for all CDIS on a regular basis as determined.
- Identifies areas needing improvement and provides education.
- Performs focused audits on identified and potential problem areas.
2.) Improves expertise of CDI staff by educating and training in areas of coding (ICD-10-CM/PCS) and quality by verifying the accuracy and completeness of staff until proficiency is achieved. Providing education and training. Monitoring and continuing education as needed/appropriate. Identifying areas needing improvement and providing appropriate education; Developing and utilizing testing tools; Providing feedback to staff and supervisor on a regular basis.
3.) Coordinates reviews and responses relating to quality reviews, queries, and clinical denials by:
Reviewing records and documentation
Preparing appropriate written communication.
Meeting with other parties to reach consensus.
4.) Provides additional educational opportunities and services by:
Conducting in-service sessions or identifying and obtaining services of appropriate “experts”;
Assisting other departments with education for coding issues.
5.) Participates in Special Projects.
6.) Participates in CDI/Coding ongoing education and training.
7.) Performs and oversees the administrative duties of the CDI team which includes but is not limited to Kronos, PTO requests, staff schedules, productivity/accuracy reports, etc.
Qualifications
Education
Graduate of an accredited school of nursing with current RN licensure in the State of Florida or Certified Clinical Documentation Specialist (CCDS)
Licensure/Certification/Registration
Registered Nurse (RN) or Certified Clinical Documentation Specialist (CCDS)
Special Skills/Qualifications/Additional Training/Experience Required
- Must be able to read, write, speak and understand English
- Minimum 5 years of recent clinical experience in a hospital setting.
- Minimum 5 years recent experience as a CDI Specialist.
- Utilization Management, Case Management, Quality Improvement or Inpatient Coding experience preferred.
- Coding audit experience preferred.
- Must have strong knowledge of ICD-10 CM/PCS and proficiency with Microsoft Windows Operating Systems and Office applications such as Word, Excel, PowerPoint, and coding/grouping software.
- Able to work well with minimal supervision.
- Able to communicate clearly both written and verbally.
- Able to generate reports for management review that present audit results in a clear manner.
- Able to meet deadlines and respond well to frequent changes in regulation.
- Able to maintain positive and productive relationships with internal and external teams and customers.
- Able to work independently and be a self-starter
