Tampa General Hospital
Clinical Documentation Improvement (CDI) Lead
Tampa General Hospital, Tampa, Florida, us, 33646
Overview
Under general supervision of the CDI Manager following established policies, procedures and professional guidelines serves as a Lead CDI Specialist and second level reviewer for the department. The CDI Lead is an expert clinician who works in partnership with multidisciplinary teams, including but not limited to Coding, Quality, Infection Control and medical staff to improve the quality and accuracy of the medical record documentation. The CDI Lead monitors the accurate reporting of SOI/ROM scores and MCC/CC capturerates for DRGs assigned. The CDI Lead maintains clinical and professional competencies for subject matter expertise in clinical documentation improvement concepts. They are responsible for concurrently reviewing inpatient medical records to identify vague, inconsistent or incomplete documentation within the medical record and assign the most appropriate medical severity diagnostic related group (MS-DRG). Further clarification of the principal and secondary diagnoses is carried out by collaborating with the physician(s) and/or care provider designees as appropriate. Participates in the educational and onboarding process of new team members. Responsibilities
The CDI Lead conducts concurrent reviews of inpatient records to identify vague, inconsistent, or incomplete documentation and assigns the most appropriate MS-DRG. Collaborates with physicians and care providers to clarify principal and secondary diagnoses. Partners with multidisciplinary teams to improve documentation quality and reporting accuracy for SOI/ROM, MCC/CC capture rates, and DRG assignment. Participates in the educational and onboarding process for new team members and supports ongoing training and quality improvement initiatives. Qualifications
RN, Bachelors Degree Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) or obtain and maintain certification within one year of employment Greater than 5 years clinical experience and greater than 3 years experience as a Clinical Documentation Improvement Specialist Preferred clinical experience with acute care at a large facility Preferred experience with 3M360 Clinical Documentation and EPIC electronic medical record Excellent communication and interpersonal skills; ability to communicate verbally and in writing with individuals of varying educational levels Credible with Physician leadership Significant financial and analytical skills Word, Outlook, Excel, PowerPoint experience preferred Analytical skills necessary to clinically assess medical records
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Under general supervision of the CDI Manager following established policies, procedures and professional guidelines serves as a Lead CDI Specialist and second level reviewer for the department. The CDI Lead is an expert clinician who works in partnership with multidisciplinary teams, including but not limited to Coding, Quality, Infection Control and medical staff to improve the quality and accuracy of the medical record documentation. The CDI Lead monitors the accurate reporting of SOI/ROM scores and MCC/CC capturerates for DRGs assigned. The CDI Lead maintains clinical and professional competencies for subject matter expertise in clinical documentation improvement concepts. They are responsible for concurrently reviewing inpatient medical records to identify vague, inconsistent or incomplete documentation within the medical record and assign the most appropriate medical severity diagnostic related group (MS-DRG). Further clarification of the principal and secondary diagnoses is carried out by collaborating with the physician(s) and/or care provider designees as appropriate. Participates in the educational and onboarding process of new team members. Responsibilities
The CDI Lead conducts concurrent reviews of inpatient records to identify vague, inconsistent, or incomplete documentation and assigns the most appropriate MS-DRG. Collaborates with physicians and care providers to clarify principal and secondary diagnoses. Partners with multidisciplinary teams to improve documentation quality and reporting accuracy for SOI/ROM, MCC/CC capture rates, and DRG assignment. Participates in the educational and onboarding process for new team members and supports ongoing training and quality improvement initiatives. Qualifications
RN, Bachelors Degree Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) or obtain and maintain certification within one year of employment Greater than 5 years clinical experience and greater than 3 years experience as a Clinical Documentation Improvement Specialist Preferred clinical experience with acute care at a large facility Preferred experience with 3M360 Clinical Documentation and EPIC electronic medical record Excellent communication and interpersonal skills; ability to communicate verbally and in writing with individuals of varying educational levels Credible with Physician leadership Significant financial and analytical skills Word, Outlook, Excel, PowerPoint experience preferred Analytical skills necessary to clinically assess medical records
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