Beth Israel Lahey Health
Clinical Documentation Improvement (CDI) Director
Beth Israel Lahey Health, Boston, Massachusetts, us, 02298
Clinical Documentation Improvement (CDI) Director
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Clinical Documentation Improvement (CDI) Director
role at
Beth Israel Lahey Health .
Under the direction of the Beth Israel Lahey Health (BILH) Vice President, Mid‑Revenue Cycle, the Director of Clinical Document Improvement (CDI) is primarily responsible for managing all employees and activities within the Clinical Documentation Program for multiple facilities across the BILH organization.
This role will assist in leading continuous improvement in documentation strategies by working closely with the Chief Medical Officers, Physician Advisors, and employed physicians. The Director of CDI will also be accountable for direct oversight of the CDI team members, which includes hiring, onboarding, and continued training.
This leader will monitor the success of the team by trending metrics such as CMI, MCC capture, and service line DRG opportunities. The role will manage staffing dependent on the needs of the facility and will be involved in the direction and education of all phases of the Clinical Documentation Specialist role, providing feedback through internal audits and continuous feedback.
Job Description Essential Duties & Responsibilities
Report monthly CDI metrics, trends, and opportunities to the CDI leaders and CDI Steering Committee.
Interpret CDI metrics and trends that result in needed outcomes.
Evaluate the CDI program initiatives via ongoing metric analysis, tracking, and reporting findings.
Collaborate with the CDI team to help identify patterns, trends, and variations in clinical documentation and code assignments.
Demonstrate a strong understanding of case mix index, MCC/CC capture, the severity of illness/risk of mortality, LOS, and risk adjustment diagnoses.
Participate in multidisciplinary meetings as it relates to CDI involvement.
Identify the need for additional training and resources for the success of the CDI team.
Provide concentrated daily oversight and direction to Clinical Documentation Specialists and the CDI Team and Program.
Review inpatient medical records prospectively to ensure that care is recorded in language that payers can interpret and which accurately and completely depicts the acuity of the patient and resources expended.
Review surgical procedures to ensure documentation is accurate for ICD/10‑PCS code assignments and institutionalize documentation practice that accurately depicts patient acuity and resources expended, adhering to coding clinic and hospital compliance guidelines.
Create and implement training and development for nursing staff, physicians, and mid‑level practitioners addressing documentation issues and variances.
Work with CDI clinicians, coders, and all members of the healthcare team to ensure accurate and timely clinical documentation in the medical record.
Develop, maintain, and improve upon effective and accurate IS systems for managing, tracking, and analyzing data (including work with Fiscal IS Decision Support).
Track DRG assignments against national benchmarks to identify documentation variances.
Identify potential solutions, whether general education or targeted interventions, to improve inconsistencies.
Review payer denials and assist in the preparation of appeals when appropriate.
Develop interventions to prevent subsequent denials for the same problem where ambiguity or incompleteness of documentation has led to a denial.
Provide ongoing education to Clinical Documentation Specialists on clinical topics.
Periodically review and update Clinical Documentation policies and guidelines.
Minimum Qualifications
Bachelor’s degree in Nursing or MBBS required.
CCDS required within 6 months of hire.
Minimum 5 years of experience in CDI and/or Coding with progressive leadership roles.
Skills, Knowledge & Abilities
Experience with Microsoft Office 365.
Excellent communication and interpersonal skills.
Knowledge of Epic environment and 3M encoder.
Working knowledge of ICD‑10 CM and PCS coding and IPPS.
Strong planning and problem‑solving skills.
Ability to analyze information and processes.
Motivation to develop and maintain internal and external relationships.
Interpretation of data that lends to strategic leadership.
Expert understanding of quality metrics such as PSIs, HACs, and mortalities.
Preferred Qualifications & Skills
Master’s degree in Nursing, Healthcare Administration, or other healthcare‑related field.
Pay Range $159,994.00 USD – $184,995.00 USD
This pay range represents the annual base salary the organization reasonably expects to pay for this position at this time. Actual compensation is determined based on factors such as seniority, education, training, relevant experience, certifications, geography, job responsibilities, or other permissible factors.
All staff must be vaccinated against influenza as a condition of employment.
Equal Opportunity Employer / Veterans / Disabled.
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Clinical Documentation Improvement (CDI) Director
role at
Beth Israel Lahey Health .
Under the direction of the Beth Israel Lahey Health (BILH) Vice President, Mid‑Revenue Cycle, the Director of Clinical Document Improvement (CDI) is primarily responsible for managing all employees and activities within the Clinical Documentation Program for multiple facilities across the BILH organization.
This role will assist in leading continuous improvement in documentation strategies by working closely with the Chief Medical Officers, Physician Advisors, and employed physicians. The Director of CDI will also be accountable for direct oversight of the CDI team members, which includes hiring, onboarding, and continued training.
This leader will monitor the success of the team by trending metrics such as CMI, MCC capture, and service line DRG opportunities. The role will manage staffing dependent on the needs of the facility and will be involved in the direction and education of all phases of the Clinical Documentation Specialist role, providing feedback through internal audits and continuous feedback.
Job Description Essential Duties & Responsibilities
Report monthly CDI metrics, trends, and opportunities to the CDI leaders and CDI Steering Committee.
Interpret CDI metrics and trends that result in needed outcomes.
Evaluate the CDI program initiatives via ongoing metric analysis, tracking, and reporting findings.
Collaborate with the CDI team to help identify patterns, trends, and variations in clinical documentation and code assignments.
Demonstrate a strong understanding of case mix index, MCC/CC capture, the severity of illness/risk of mortality, LOS, and risk adjustment diagnoses.
Participate in multidisciplinary meetings as it relates to CDI involvement.
Identify the need for additional training and resources for the success of the CDI team.
Provide concentrated daily oversight and direction to Clinical Documentation Specialists and the CDI Team and Program.
Review inpatient medical records prospectively to ensure that care is recorded in language that payers can interpret and which accurately and completely depicts the acuity of the patient and resources expended.
Review surgical procedures to ensure documentation is accurate for ICD/10‑PCS code assignments and institutionalize documentation practice that accurately depicts patient acuity and resources expended, adhering to coding clinic and hospital compliance guidelines.
Create and implement training and development for nursing staff, physicians, and mid‑level practitioners addressing documentation issues and variances.
Work with CDI clinicians, coders, and all members of the healthcare team to ensure accurate and timely clinical documentation in the medical record.
Develop, maintain, and improve upon effective and accurate IS systems for managing, tracking, and analyzing data (including work with Fiscal IS Decision Support).
Track DRG assignments against national benchmarks to identify documentation variances.
Identify potential solutions, whether general education or targeted interventions, to improve inconsistencies.
Review payer denials and assist in the preparation of appeals when appropriate.
Develop interventions to prevent subsequent denials for the same problem where ambiguity or incompleteness of documentation has led to a denial.
Provide ongoing education to Clinical Documentation Specialists on clinical topics.
Periodically review and update Clinical Documentation policies and guidelines.
Minimum Qualifications
Bachelor’s degree in Nursing or MBBS required.
CCDS required within 6 months of hire.
Minimum 5 years of experience in CDI and/or Coding with progressive leadership roles.
Skills, Knowledge & Abilities
Experience with Microsoft Office 365.
Excellent communication and interpersonal skills.
Knowledge of Epic environment and 3M encoder.
Working knowledge of ICD‑10 CM and PCS coding and IPPS.
Strong planning and problem‑solving skills.
Ability to analyze information and processes.
Motivation to develop and maintain internal and external relationships.
Interpretation of data that lends to strategic leadership.
Expert understanding of quality metrics such as PSIs, HACs, and mortalities.
Preferred Qualifications & Skills
Master’s degree in Nursing, Healthcare Administration, or other healthcare‑related field.
Pay Range $159,994.00 USD – $184,995.00 USD
This pay range represents the annual base salary the organization reasonably expects to pay for this position at this time. Actual compensation is determined based on factors such as seniority, education, training, relevant experience, certifications, geography, job responsibilities, or other permissible factors.
All staff must be vaccinated against influenza as a condition of employment.
Equal Opportunity Employer / Veterans / Disabled.
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