Lead, Clinical Documentation Excellence Specialist

Job Summary

 

The Lead, Clinical Documentation Excellence Specialist (CDES). In this pivotal role, you will oversee clinical documentation efforts, mentor a team of specialists, and collaborate with providers to enhance documentation quality and ICD-10 coding accuracy. Your leadership will drive improvements in clinical documentation practices, support organizational goals, and ensure accurate representation of patient care and complexity.

 

Duties and Responsibilities

 

Primary Responsibilities

• Team Leadership and Mentorship:
• Provide mentorship, training, and oversight to the Clinical Documentation Excellence (CDE) specialist team, including conducting regular overreads, offering feedback, and promoting best practices.
• Act as a resource for the team by addressing complex documentation or coding scenarios and ensuring consistency in reviews.
• Assist in onboarding new CDE specialists, including developing training materials and facilitating initial education sessions.
• Clinical Documentation Program Development:
• Design and implement strategies to enhance documentation accuracy, ICD-10 coding specificity, and risk adjustment outcomes.
• Collaborate with leadership to define key performance indicators (KPIs) for the CDE program and regularly monitor progress.
• Drive initiatives to align documentation practices with organizational goals, such as risk adjustment optimization and quality metric performance.
• Provider Collaboration and Education:
• Partner with providers to improve clinical documentation practices, providing targeted education on coding specificity, risk adjustment, and compliance standards.
• Conduct provider-focused training sessions to address common documentation challenges and share feedback trends.
• Documentation Review and Query Management:
• Conduct timely and thorough outpatient documentation reviews to identify gaps in clinical accuracy and coding specificity.
• Develop high-quality queries to clarify documentation, ensuring alignment with AHIMA/ACDIS standards and payer requirements.
• Monitor query response trends and provide recommendations for improvement.
• Program Oversight and Reporting:
• Create and deliver regular performance reports to leadership, summarizing key metrics such as query response rates, documentation improvement trends, and coding accuracy.
• Collaborate with the Quality and Risk Adjustment teams to ensure alignment of documentation efforts with value-based care goals.
• Participate in interdisciplinary team meetings, contributing insights on clinical documentation improvement strategies.
• Technology and Process Improvement:
• Leverage EMR tools to streamline documentation review workflows and identify automation opportunities.
• Propose enhancements to existing documentation processes and workflows to improve efficiency and reduce provider burden.
• Stay informed on EHR upgrades, payer requirements, and regulatory changes, and incorporate updates into team workflows.

 

Minimum Qualifications

 

Required Qualifications:

• Minimum of 5 years of combined, or equivalent, experience as a clinical RN, Foreign Medical Graduate with CDI certification, outpatient certified medical coder with CDI certification.
• Associates or Bachelor’s degree in a health science or related field of study
• Proven experience in Clinical Documentation Improvement.
• Demonstrated ability to build trusted relationships with medical and/or behavioral health providers.
• Ability to work independently, self-motivate, and adapt to change.
• Proficiency working in a Microsoft environment, including Microsoft Word, Excel, PowerPoint, Outlook, and Electronic Medical Records.

Preferred Qualifications:

• Experience applying risk adjustment concepts in CDI reviews.
• CCDS, CDIP, CDEO, or CCS certification.