Educator-Clinical Documentation Integrity

J  o  b    D  e  s  c  r  i  p  t  i  o  n

          Joy                         Care                      Competence                    Respect

Position Summary

The Clinical Documentation Integrity (CDI) Educator works within an assigned market to promote the capture of clinical severity to support the level of service provided to the patient.  The position performs audits of records on CDI Specialists and Providers in combination with using data captured in other systems to identify opportunities for remediation and education for standardization and compliance.  As part of remediation, this position will interact 1:1 or in groups with providers or CDI colleagues to clarify information in patient records, educate to remediate issues identified and discern patterns and trends in data showing that remediation has been successful.

Associates degree in nursing, health information management or related field is required.

Bachelor's degree in nursing, health information management or related field is preferred.

High School Diploma or equivalent plus 3 years’ experience in health information management or a related field may be considered in lieu of an Associates degree.

3 years of CDI (Clinical Documentation Integrity) experience is required.

Registered Nurse (RN) license in IL or WI, or RHIT (Registered Health Information Technician), or RHIA (Registered Health Information Administrator), or CCS (Certified Coding Specialist) is required. Wisconsin:  RNs may practice with a valid multi-state RN license as outlined in the Nurse Licensure Compact rules.

Incumbents must obtain a Certified Clinical Documentation Specialist (CCDS), Certified Documentation Integrity Practitioner (CDIP) or Certified Coding Specialist (CCS) within 1 year of hire.  For candidates with a CCS, a CCDS or CDIP is required.

Possesses a high degree of initiative.

Demonstrates good analytic skills, as well as excellent communication and problem-solving skills.

Ability to inspire and develop colleagues to meet organizational goals.

Experience in a customer service or clinical setting.   

Ability to work within tight timeframes and meet strict deadlines.

Seeks to acquire knowledge in area of specialty.

Demonstrated ability where the competencies of auditing, teaching and providing feedback to providers were performed.

Incumbent is available to be onsite at an HSHS facility 25% of the time if required to participate in onsite meetings with providers, round on patient units, provide feedback and education to nursing and other departments and promote the CDI Program within areas of focus such as residency programs. 

Analyzes and evaluates data related to inpatient reimbursement, Quality metrics, CDI metrics, and other pertinent data points via chart review and other methods. Works in collaboration with the CDI and Coding team members to ensure accurate and timely documentation that supports the coding process. Responsible for coaching, mentoring and monitoring the work of Level I and Level II CDI Specialists and collaborates with CDI Department Leadership at the Manager and Director Level to execute the department goals, including financial and clinical outcome measures.

Works collaboratively with other departments to ensure the integrity of the medical record, including, but not limited to, medical, quality, nursing, and ancillary staff members.

Successfully integrate new CDI colleagues into the team including concept training, process, technology, coding guidelines, and provider/staff education, promoting their continuous development.

Performs initial case reviews and follow up reviews based on program expectations.

Monitors CDI compliance through quality audits and data analysis.

Identifies documentation integrity opportunities and educates groups and individuals within and external to the CDI team regarding documentation integrity, coding guidelines, and reimbursement.

Assists manager with colleague scheduling, provides input regarding colleague productivity Promotes good morale and cooperation within the CDI team and across the HSHS health system.

Serves as frontline resource and lead for the functional activities performed by the CDI team.

Represents CDI Department on various committees and meetings.

Possess the information, skill, and understanding of the work to be performed.  Actively participates in continuing education opportunities and maintains certifications, licensure as appropriate.

Abides by all safety requirements including demonstrating proper hand hygiene and wearing of Personal Protective Equipment (PPE), if applicable. 

Complies with all standards, policies and procedures including dress code, attendance and punctuality.  Attends required in-services and meetings and completes all mandatory competencies by deadline. Commits to keeping all patient, student or colleague information confidential and maintains ongoing communication and collaboration with team members. 

The purpose of this job description is to provide a summary of the major responsibilities performed by colleagues in this position. Colleagues may be requested to perform tasks other than those specifically presented in this job description.  Variances in job duties performed may exist between facilities, and colleagues may perform other related duties as assigned to meet the needs of the organization.

PHYSICAL, MENTAL AND ENVIRONMENTAL REQUIREMENTS

Physical, Mental and Environmental Requirements Category:

Administrative

Standing

X

Walking

X

Sitting

X

Lifting

X

20 lbs.

Carrying

X

20 lbs.

Pushing

X

20 lbs.

Pulling

X

20 lbs.

Climbing

X

Balancing

X

Stooping

X

Kneeling

X

Crouching

X

Crawling

X

Reaching

X

Use of Hands/Dexterity

X

Talking

X

Hearing

X

Eye/Hand/Foot Coordination

X

Extreme Cold

X

Extreme Heat

X

Humid

X

Wet

X

Noise

X

Hazards

X

Temperature Change

X

Atmospheric Conditions

X

Vibration

X

Other