Clinical Documentation Specialist Lead

Job Description

Provides support of clinical documentation improvement activities in an effort to support accuracy and quality in the patient records and to ensure that coded diagnoses are an accurate reflection of the patient's clinical status and care. The CDI Lead provides a key role in maintaining the long-term system success of CDI by providing inpatient auditing as well as program reporting, applications support and operations functions.

Associate Degree required, Bachelor's preferred. American Health Information Management Association (AHIMA) credential. Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT) required. 1-3 years ongoing inpatient coding and abstracting experience in ICD-9-CM and DRGs required.

A minimum of one year auditing experience required. Prior documentation improvement experience highly desired. At least one of the following is required:

RHIA, RHIT, or CCS. The following are preferred: CDIP, CCDS, clinical degree, or ICD-10 certification or trainer designation. Full time days.

Benefits

• Major medical, dental, and vision insurance

• Paid time off

• 401(k)

Must possess at least five years of acute hospital nursing experience (e.g. medical/surgical unit, intensive care). Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management and/or inpatient coding considered a plus. ICU/Critical Care Experience strongly desired.

Prior experience in clinical documentation improvement, ICD coding and MS-DRGs preferred. Prior experience educating physicians/providers preferred. Previous experience working in a clinical documentation improvement department or as a consultant strongly encouraged.

Minimum of one-year auditing experience strongly encouraged. This individual must possess a comprehensive knowledge of medical terminology, disease processes and clinical competency. Candidate must possess excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills.

Strong critical thinking skills and ability to integrate knowledge is necessary. Prioritization and organizational skills required. Must exhibit the ability to educate members of the healthcare team about clinical documentation.

Individual must demonstrate data quality and integrity skills. To perform this job successfully, an individual should have strong working knowledge of word processing software, spreadsheet software and reporting software. Also, experience working with encoder software, clinical documentation improvement software and the electronic medical record is preferred.

English is required for both verbal and written communication. Ability to communicate effectively at a high level is required.

Grandview Medical Center, a 434-bed regional referral center and tertiary-care facility, is located in Birmingham, AL., and is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Grandview Medical Center offers programs and services in all medical and surgical areas, including Cardiology, Oncology, Neurology, Women's Health, Mental Health, Digestive Diseases, Orthopedics, Physical Medicine and Rehab, Sports Medicine and Emergency Care. There are more than 600 physicians on the Grandview medical staff representing 30 specialties and subspecialties. The hospital has been named an accredited program for Metabolic and Bariatric surgery by ASMBS & ACS as well as an accredited chest pain center.

At Grandview Medical Center, we believe in the power of great people and a team approach to make a difference in the health and well-being of the people and communities we serve. Compassion, a commitment to excellence, a safe environment, and opportunities for personal growth define our culture. Whether you work with patients every day or support those who do, you can make an impact by being a part of our team.

Grandview Medical Center provides equal employment opportunity to all employees and applicants for employment regardless of any individual's race, color, religion, sex, sexual orientation, gender identity, national origin, age, citizenship, military status, disability, genetic information or any other protected class status in accordance with applicable federal, state, and local laws.