Clinical Document Improvement Specialist Lead – Oxnard, CA - $5K Sign on Bonus!!(Job Number:702665)
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The Lead Clinical Document Improvement Specialist - (LCDS) is responsible for providing CDI program oversight and day to day CDI implementation of processes related to the concurrent review of the clinical documentation in the inpatient medical record of Optum 360 clients’ patients. The goal of the LCDS oversight and practice is to support the CDI manager function by providing staff oversight, serve as an additional resource as well as perform CDI role function. LCDS will assess the technical accuracy, specificity, and completeness of provider clinical documentation, and to ensure that the documentation explicitly identifies all clinical findings and conditions present at the time of service.
This position does not have patient care duties, does not have direct patient interactions, and has no role relative to patient care.
In this position the LCDS will utilizing the Optum™ CDI 3D technology that is assisting hospitals to improve data quality to accurately reflect the quality of care provided and ensure revenue integrity. Our three-dimensional approach to CDI technology, paired with best-practice adoption methodology and change management support, is helping hospitals make a real impact on CDI efficiency and effectiveness.
- Increase in identification of cases with CDI opportunities, with automated review of 100% of records.
- Improved tracking, transparency and reporting related to CDI impact, revenue capture, trending and compliance.
- Easing the transition to ICD-10 by improving the specificity and completeness of clinical documentation, resulting in more accurate coding.
***This will be an onsite position located at St. John’s Regional Medical Center in Oxnard, CA with some travel to St. John’s Pleasant Valley Hospital in Camarillo, CA ***
$5,000 SIGN ON BONUS!!!
Lead CDI Responsibilities:
- Assists CDI Manager with chart audits, quality audit and KPI audits
- Assists CDI Manager with running reports, attends on site meetings as directed
- Oversees CDI staff training and orientation
- Oversees and leads workflow for CDI staff
- Develops physician teaching and on site presentations
- Assist CDI manager with projects or tasks as needed
CDI Primary Responsibilities:
- Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the patient condition and acuity of care provided
- Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity
- Provides expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating recommendations for improvement, and the rational for the recommendations
- Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality
- Performs regular rounding with unit-based physicians
- Provides face-to-face educational opportunities with physicians on a daily basis
- Provides complete follow through on all requests for clarification or recommendations for improvement
- Leads the development and execution of physician education strategies resulting in improved clinical documentation
- Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes
- Ensures effective utilization of the Midas Clinical Documentation Improvement Focus Study, documenting all verbal, written, electronic clarification activity
- Utilizes only the Optum360 approved forms, whether paper or electronic
- Proactively develops a reciprocal relationship with the HIM Coding Professionals
- Coordinate and conducts regular meeting with HIM Coding Professionals to monitor retrospective query rate and address issues
- Engages and consults with Physician Advisor when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
- Actively engages with Care Coordination and the Quality Management teams to continually evaluate and spearhead clinical documentation improvement opportunities
Job Clinical Analysis & Consulting
Primary Location US-CA-Oxnard
Organization O360 Dignity Health Middle Ops
Number of Openings 1