CDI Lead Specialist - Saint Joseph Hospital East

JOB SUMMARY Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management. Assist with overseeing department workflow and metrics. Create reports used to make strategic decisions. Educate and train department staff. Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians’ clinical documentation.

ESSENTIAL DUTIES AND RESPONSIBILITIES Include the following. Others may be assigned.

Record Review

Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) initiate a review worksheet.

Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.

Formulates physician queries regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.

Collaborates with case managers, nursing staff and other ancillary staff regarding interaction with physicians regarding documentation and to resolve physician queries prior to discharge.

Lead Responsibilities

Provides daily support, mentoring, training to new hires as well as existing staff.

Provides assistance in managing escalated issues and special projects as needed to supervisors and managers. CDI staff coverage.

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