Position Summary

Work closely with organizational leadership and the Department Director to plan, develop, implement and monitor Clinical Documentation Improvement (CDI) education programs for CDI Specialists, coding specialists, clinical nursing staff, clinical nursing management, Medical Staff, Providers, Residents, Fellows, Medical Students and ancillary department staff as needed in support of accurate clinical documentation, coding, billing and reimbursement. Educate and mentor members of the CDI team on the review and query functions within the CDI program in order to meet and maintain organizational goals and objectives, to support medical necessity of services provided, to support patient safety, quality and outcomes, to maintain regulatory compliance, and to support third-party payer requirements related to the accuracy of clinical documentation. Conducts clinically-based concurrent and retrospective review of medical records documentation in support of accurate MS-DRG and APR-DRG (severity of illness and risk of mortality) assignment. Identifies opportunities for improving the quality of medical record documentation and confers with the caregiver regarding additional documentation required. Facilitates and enhances the coding and DRG process alignment between physicians and coding staff. Retrospective reviews to be conducted by the CDI Educator are determined both internally and by requirements/requests of external payers or regulatory agencies. Collects CDI data for analysis and report generation as indicated.

Minimum Qualifications

• Three years of Clinical Documentation Improvement experience in an acute care hospital required.
• Bachelor's degree in nursing or related field required. Certifications/Licensure Kentucky RN license (OR) RN license in a State recognized by the Kentucky Nurse Licensure Compact Act required effective June 1, 2007.
• CCS or CCDS certification required within six months of hire or placement.