Clinical Documentation Integrity Specialist Lead Day Shift

Overview

Responsible for ongoing quality review and assessment of inpatient hospital charts through concurrent and retrospective second-level reviews to identify documentation and coding opportunities. Analyzes trends, prepares reports for management review, and supports process improvements to optimize opportunity capture within the Clinical Documentation Integrity team. Serves as a key point of contact for CDI data requests and contributes to staff education and training initiatives under the direction of the Clinical Documentation Integrity Manager.

• Conducts ongoing quality review and assessment of inpatient hospital charts.
• Performs concurrent and retrospective second-level reviews for identified opportunities and retrospective requests, including but not limited to:
  • Low-acuity discharges to hospice and mortalities
  • Low-acuity DRGs with extended length of stay (LOS)
  • Targeted DRG opportunities identified through analytics
• Prepares reports for management review and identifies trends, findings, and improvement opportunities.
• Develops and recommends strategic approaches and process refinements to optimize opportunity capture within the CDS team, including prioritization and assignment based on retrospective requests and second-level reviews.
• Serves as the primary point of contact for internal and external Clinical Documentation Integrity (CDI) data requests.
• Collaborates with leadership to support education and training initiatives for staff, under the direction of the Clinical Documentation Integrity Manager.
• Performs additional duties as assigned in support of departmental and organizational goals.

• Graduate of an accredited school of nursing with a current RN license in the State of Florida, or International Medical Graduate with a Medical School Diploma
• Certified Clinical Documentation Specialist (CCDS) certification preferred

• Minimum of five (5) years of recent clinical experience in a hospital setting
• Experience in Utilization Management, Case Management, Quality Improvement, or Inpatient Coding preferred

• Strong knowledge of ICD-10-CM/PCS
• Proficiency with Microsoft Windows operating systems and Microsoft Office applications, including Word, Excel, and Power Point
• Experience with coding and grouping software

• Ability to work effectively with minimal supervision
• Strong written and verbal communication skills
• Ability to generate clear, concise reports for management review, including audit results
• Ability to meet deadlines and respond effectively to frequent regulatory changes
• Demonstrated ability to maintain positive and productive relationships with internal and external teams and customers
• Ability to work independently and function as a self-starter