Lead Clinical Documentation | Health Info & Record Management | Exempt

Overview:

UF Health Spanish Plaines Hospital has been serving residents of The Villages as well as patients in Lake, Sumter and Marion counties since 2002.

In conjunction with the Clinical Documentation Integrity Manager, contributes to the development of educational and training opportunities for staff.

Responsibilities:

1. ) Contributes to the accuracy of CDI functions by performing quality reviews.

• Performs reviews for all categories of records coded at least quarterly.
• Performs quality reviews for all CDIS on a regular basis as determined.
• Identifies areas needing improvement and provides education.
• Performs focused audits on identified and potential problem areas.

1. ) Improves expertise of CDI staff by educating and training in areas of coding (ICD-10-CM/PCS) and quality by verifying the accuracy and completeness of staff until proficiency is achieved. Providing education and training. Monitoring and continuing education as needed/appropriate. Identifying areas needing improvement and providing appropriate education; Developing and utilizing testing tools; Providing feedback to staff and supervisor on a regular basis.
2. ) Coordinates reviews and responses relating to quality reviews, queries, and clinical denials by:

Reviewing records and documentation

Preparing appropriate written communication.

1. ) Provides additional educational opportunities and services by:

1. ) Participates in Special Projects.
2. ) Participates in CDI/Coding ongoing education and training.
3. ) Performs and oversees the administrative duties of the CDI team which includes but is not limited to Kronos, PTO requests, staff schedules, productivity/accuracy reports, etc.

Qualifications:

• Graduate of an accredited school of nursing with current RN licensure in the State of Florida or Certified Clinical Documentation Specialist (CCDS)

• Registered Nurse (RN) or Certified Clinical Documentation Specialist (CCDS)

• Must be able to read, write, speak and understand English
• Minimum 5 years of recent clinical experience in a hospital setting.
• Minimum 5 years recent experience as a CDI Specialist.
• Utilization Management, Case Management, Quality Improvement or Inpatient Coding experience preferred.
• Coding audit experience preferred.
• Must have strong knowledge of ICD-10 CM/PCS and proficiency with Microsoft Windows Operating Systems and Office applications such as Word, Excel, PowerPoint, and coding/grouping software.
• Able to work well with minimal supervision.
• Able to communicate clearly both written and verbally.
• Able to generate reports for management review that present audit results in a clear manner.
• Able to meet deadlines and respond well to frequent changes in regulation.
• Able to maintain positive and productive relationships with internal and external teams and customers.
• Able to work independently and be a self-starter