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Job Summary:
The Clinical Documentation Integrity (CDI) Education Lead collaborates with key stakeholders such as the CDI Leadership team, coding team members, providers, facility and service-line operational leadership, CDI & Coding auditors, and others to train providers on documentation best practices aimed at improving clinical documentation and coding accuracy. The CDI Education Lead is also responsible for training clinical documentation specialists to enhance their skills for CDI operations, with the goal of improving the accuracy of patient record documentation. This role involves working with the CDI Leadership team to develop and deliver education for providers on documentation best practices and for all CDI team members, covering areas like new employee orientations, skills training, team building, customer service, and change management. The aim is to ensure that clinical information in medical records is accurately recorded to reflect the appropriate clinical severity level for services provided to patients. Additionally, this role utilizes data trends, including CDI KPIs and audit results, to identify educational opportunities for providers and areas where the CDI team needs skill enhancement, develops/suggests training to support clinical documentation and coding accuracy.
Core Responsibilities and Essential Functions:
1. Ensures the growth of CDI team’s skills & competencies, and adaptation to the changes in guidelines for accurate documentation and coding.
a) Assesses the areas where the providers and CDI team need to improve their knowledge and skills to stay current with the organizational and industry updates, as well as the changes in documentation and coding guidelines and informs the CDI Leadership team about the findings.
b) Initiates gathering topics, preparing, and providing regular CDI education to providers and team members based on data trends, audit results, industry events and leadership needs
c) Leverages the resources and technologies that are accessible to provide education and training to the providers and CDI team based on the identified needs, and ensure the improvement of the knowledge and skills from the provided education
d) Creates tailored CDI learning materials to address the learning needs of the providers and CDI team based on the data trends, audit results, industry events and leadership
e) Provides live and recorded education and training to the providers and CDI team, and ensures that the education improves the knowledge and skills of the team
f) Collaborates with the CDI Leadership team to create and deliver education and training for providers, new staff orientations, skills development, teamwork, customer service, and change management
g) Provides education and training to the providers and clinical documentation specialists in a timely manner, based on the results of the audits done by the CDI and Coding teams
h) Works with the CDI team to identify the provider education and training needs to make the documentation in the patient records more accurate
i) Helps with developing education material for the providers based on the data trends, audit findings, industry events and leadership objectives
j) Assists CDI Technology Lead with testing of future technology enhancements to improve CDI and provider workflows for accurate documentation and coding
k) Supports CDI Leadership team with creating training materials for the senior executive leadership, CDI team and providers, gathering articles or other information for presentations and meetings
l) Works with CDI Leadership team to find ways to enhance CDI team’s skills & competencies to boost CDI outcomes, using methods such as shadowing CDI staff, analyzing data and trends, etc. to identify more areas of improvement.
m) Functions as a Super User with CDI Software and all other applications utilized by the CDI team.
n) Participates in new user training on technology tools as needed- o) Performs any other duties as assigned
2. Reviews clinical documentation remotely during patient admissions to identify the areas where the CDI team needs to improve their knowledge and skills to stay current with the organizational and industry updates, as well as the changes in documentation and coding guidelines.
a) Performs hospital-wide medical record reviews facilitating improvement in the quality, completeness, and accuracy of medical record documentation to ensure coding compliance, accurate reporting, and improved patient outcomes.
b) Submits electronic queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population.
c) Ensure queries are compliant, grammatically correct, concise, and free of typographical errors, and follow organizational query policies and procedures.
d) Provides appropriate follow-up on all queries.
e) Escalates immediately when queries are not timely answered to the CDI Leadership team, following the Wellstar Query Escalation process. Provides all data necessary for the CDI Leadership team to assist.
f) Reconciles all appropriate records daily in the Solventum/3M 360 Encompass CDI tool to ensure appropriate reporting is generated.
g) Provides appropriate follow up education on queries as needed
h) Notifies the CDI Manager immediately when query education is needed and provides all data necessary for the CDI Manager to assist.
i) Participates in required meetings, conference calls and presentations to the stakeholders, including the CDI staff, providers, senior executive leadership, etc.
j) Adheres to departmental Policies and Procedures.- k) Implements ideas that result in growth of CDI team’s skills & competencies, and adaptation to the changes in guidelines for accurate documentation and coding, by collaborating with the CDI Leadership Team
3. Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement. Maintains knowledge base of current medical terminology, procedures, medications, and diseases to provide accurate patient record analysis.
a) Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process.
b) Participates in assuring hospital compliance with Federal and State regulatory requirements.- c) Supports CDI Leadership team to keep the CDI team’s skills and competencies updated with the changes to documentation and coding guidelines on an on-going basis.
Job Titles Reporting to this Job:
Trust/Engagement:
Builds a culture of trust and engagement as reflected in the Great Place to Work Trust Index Survey at a direct report, workgroup and hospital/entity level.
Holds leaders accountable for behaviors that create trust and engagement.
Performs all duties and responsibilities of this position in a manner that reflects the values of WellStar.
Maintains and strengthens relationships with physicians and assures their involvement in developing systems to assure the growth of the service and the cost effective delivery of quality patient care in a manner that fosters patient and employee satisfaction.
Results Oriented Leadership:
Sets challenging and productive goals for team.
Holds team accountable for actions while providing leadership and motivation.
Provides resources and support,
Uses checkpoints and data to track progress, setting up system and processes to measure results.
Collaboration and Partnership:
Required Minimum Education:
Associate's Degree in nursing Required or
Bachelor's Degree in a healthcare-related program Required or
Doctorate Completed degree from an accredited medical school Required
Required Minimum License(s) and Certification(s):
Cert Clin Document Specialist 1.00 Required
Cert Document Improvement Prac 1.00 Required
Reg Nurse (Single State) 2.00 Required
RN - Multi-state Compact 2.00 Required
Cert Coding Spec 2.00 Required
Cert Prof Coder 2.00 Required
Reg Health Information Admin 2.00 Required
Reg Health Information Tech 2.00 Required
Additional Licenses and Certifications:
It is expected that all RN’s are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association Upon Hire Required
Required Minimum Experience:
- Minimum 2 years working in an acute care setting as a Clinical Documentation Specialist (CDS) Required and
- Minimum 5 years healthcare experience Required
- Prior experience of working as a CDI/Coding educator is highly preferred
- Prior experience of working in inpatient case management or utilization review is preferred
Required Minimum Skills:
- Strong understanding of disease processes, clinical indications and treatments; and provider documentation requirements to reflect severity of illness, risk of mortality and support the diagnosis/procedures performed for accurate clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payors
- Familiarity with encoder and current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS and APR)
- Epic and Solventum/3M 360 Encompass experience is preferred
- Expert knowledge/experience in managing all aspects of Clinical Documentation Integrity, including provider documentation quality, provider performance metrics, CDI productivity, quality, education and training, compliance auditing, data analysis and trending, report management, performance improvement initiatives
- CDI/Coding chart review experience required
- Excellent communication skills, employing tact and effectiveness
- Demonstrate effective communication and presentation skills and collaborates with medical staff, clinical departments, and key facility and service-line leadership team members
- Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives
- Excellent problem-solving skills, with the ability to recommend and implement practical and efficient solutions
- Must have proficient computer skills in Microsoft Apps, such as Word, Excel and PowerPoint, as well as CDI technology tools required for the job functions
- Must be comfortable with doing data analysis, and preparing and maintaining records and written reports
- Leverages available technologies and reporting capabilities effectively to identify areas for education for the providers and CDI & Coding staff
- Excellent time management, training, and peer development skills
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