Clinical Documentation Education Lead

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Work Shift

The Clinical Documentation Integrity (CDI) Education Lead collaborates with key stakeholders such as the CDI Leadership team, coding team members, providers, facility and service-line operational leadership, CDI & Coding auditors, and others to train providers on documentation best practices aimed at improving clinical documentation and coding accuracy. The CDI Education Lead is also responsible for training clinical documentation specialists to enhance their skills for CDI operations, with the goal of improving the accuracy of patient record documentation. This role involves working with the CDI Leadership team to develop and deliver education for providers on documentation best practices and for all CDI team members, covering areas like new employee orientations, skills training, team building, customer service, and change management. The aim is to ensure that clinical information in medical records is accurately recorded to reflect the appropriate clinical severity level for services provided to patients. Additionally, this role utilizes data trends, including CDI KPIs and audit results, to identify educational opportunities for providers and areas where the CDI team needs skill enhancement, develops/suggests training to support clinical documentation and coding accuracy.

1. Ensures the growth of CDI teams skills & competencies, and adaptation to the changes in guidelines for accurate documentation and coding.
a) Assesses the areas where the providers and CDI team need to improve their knowledge and skills to stay current with the organizational and industry updates, as well as the changes in documentation and coding guidelines and informs the CDI Leadership team about the findings.
b) Initiates gathering topics, preparing, and providing regular CDI education to providers and team members based on data trends, audit results, industry events and leadership needs
c) Leverages the resources and technologies that are accessible to provide education and training to the providers and CDI team based on the identified needs, and ensure the improvement of the knowledge and skills from the provided education
d) Creates tailored CDI learning materials to address the learning needs of the providers and CDI team based on the data trends, audit results, industry events and leadership
e) Provides live and recorded education and training to the providers and CDI team, and ensures that the education improves the knowledge and skills of the team
f) Collaborates with the CDI Leadership team to create and deliver education and training for providers, new staff orientations, skills development, teamwork, customer service, and change management
g) Provides education and training to the providers and clinical documentation specialists in a timely manner, based on the results of the audits done by the CDI and Coding teams
h) Works with the CDI team to identify the provider education and training needs to make the documentation in the patient records more accurate
i) Helps with developing education material for the providers based on the data trends, audit findings, industry events and leadership objectives
j) Assists CDI Technology Lead with testing of future technology enhancements to improve CDI and provider workflows for accurate documentation and coding
k) Supports CDI Leadership team with creating training materials for the senior executive leadership, CDI team and providers, gathering articles or other information for presentations and meetings
l) Works with CDI Leadership team to find ways to enhance CDI teams skills & competencies to boost CDI outcomes, using methods such as shadowing CDI staff, analyzing data and trends, etc. to identify more areas of improvement.
m) Functions as a Super User with CDI Software and all other applications

utilized by the CDI team.
n) Participates in new user training on technology tools as needed
o) Performs any other duties as assigned
3. Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement. Maintains knowledge base of current medical terminology, procedures, medications, and diseases to provide accurate patient record analysis.
a) Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process.
b) Participates in assuring hospital compliance with Federal and State regulatory requirements.
c) Supports CDI Leadership team to keep the CDI teams skills and competencies updated with the changes to documentation and coding guidelines on an on-going basis.
2. Reviews clinical documentation remotely during patient admissions to identify the areas where the CDI team needs to improve their knowledge and skills to stay current with the organizational and industry updates, as well as the changes in documentation and coding guidelines.
a) Performs hospital-wide medical record reviews facilitating improvement in the quality, completeness, and accuracy of medical record documentation to ensure coding compliance, accurate reporting, and improved patient outcomes.
b) Submits electronic queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population.
c) Ensure queries are compliant, grammatically correct, concise, and free of typographical errors, and follow organizational query policies and procedures.
d) Provides appropriate follow-up on all queries.
e) Escalates immediately when queries are not timely answered to the CDI Leadership team, following the Wellstar Query Escalation process. Provides all data necessary for the CDI Leadership team to assist.
f) Reconciles all appropriate records daily in the Solventum/3M 360 Encompass CDI tool to ensure appropriate reporting is generated.
g) Provides appropriate follow up education on queries as needed
h) Notifies the CDI Manager immediately when query education is needed and provides all data necessary for the CDI Manager to assist.
i) Participates in required meetings, conference calls and presentations to the stakeholders, including the CDI staff, providers, senior executive leadership, etc.
j) Adheres to departmental Policies and Procedures.
k) Implements ideas that result in growth of CDI teams skills & competencies, and adaptation to the changes in guidelines for accurate documentation and coding, by collaborating with the CDI Leadership Team
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.

• Associates Nursing or Bachelors Health Science or Accredited Program Health Science or Doctorate Medicine

All certifications are required upon hire unless otherwise stated.

• Cert Clin Document Specialist within 180 Days or Cert Document Improvement Prac within 180 Days
• Reg Nurse (Single State)-Preferred or RN - Multi-state Compact-Preferred or Cert Coding Spec-Preferred or Cert Prof Coder-Preferred or Reg Health Information Admin-Preferred or Reg Health Information Tech-Preferred

It is expected that all RNs are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association Upon Hire Required or
It is expected that all non-clinical (coding) background candidates have at least one of the following active/current certifications: (1) Certified Coding Specialist (CCS) from AHIMA, (2) Certified Professional Coder (CPC) from AAPC, (3) Registered Health Information Administrator (RHIA) from AHIMA, or (4) Registered Health Information Technician (RHIT) from AHIMA Upon Hire Required

Minimum 2 years working in an acute care setting as a Clinical Documentation Specialist (CDS) Required and
Minimum 5 years healthcare experience Required and
Prior experience of working as a CDI/Coding educator is highly preferred Preferred and
Prior experience of working as a CDI/Coding auditor is preferred Preferred and
Prior experience of working in inpatient case management or utilization review is preferred Preferred and

Strong understanding of disease processes, clinical indications and treatments; and provider documentation requirements to reflect severity of illness, risk of mortality and support the diagnosis/procedures performed for accurate clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payors
Familiarity with encoder and current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS and APR)
Epic and Solventum/3M 360 Encompass experience is preferred
Expert knowledge/experience in managing all aspects of Clinical Documentation Integrity, including CDI productivity, quality, education and training, compliance auditing, data analysis and trending, report management, performance improvement initiatives
CDI/Coding chart review experience required
Excellent communication skills, employing tact and effectiveness
Demonstrate effective communication and presentation skills and collaborates with medical staff, clinical departments, and key facility leadership team members
Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives
Excellent problem-solving skills, with the ability to recommend and implement practical and efficient solutions
Must have proficient computer skills in Microsoft Apps, such as Word, Excel and PowerPoint, as well as CDI technology tools required for the job functions
Must be comfortable with doing data analysis, and preparing and maintaining records and written reports
Leverages available technologies and reporting capabilities effectively to identify areas for education for the CDI & Coding staff
Excellent time management, training, and peer development skills.

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