Shift: Full time, Days (Not a remote job)

Reporting to the Manager of Clinical Documentation, the Lead Clinical Documentation Specialist provides second level reviews for identified cases, provides complex chart reviews, and uses advanced CDI and coding knowledge to drive performance, identify opportunity, improve quality outcome measures and prevent denials. The Lead Clinical Documentation Specialist will have a role in providing education, including orientation and mentoring of new employees. The Lead may be asked to assist with cases on escalation and with denials/appeal letters. The Lead will facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. The Lead serves as a resource and mentor to all members of the health care team for coding and documentation guidelines.

1. Coordinates Education between the CDI team and other health care team members and physicians on appropriate medical record documentation. Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends in documentation. Confers with other clinical care providers to explain the importance of clear and concise documentation. Provides one-on-one education to physicians as appropriate.

2. Functions as the super-user and trainer for the Clinical Documentation Improvement program and all application software used by CDI staff.

3. Interacts with treating physicians, nurses, case managers, quality staff and coders to ensure complete and compliant treating physician documentation to support MS-DRG and APR-DRG assignment, as well as improvement in SOI and ROI documentation. Supports CMS quality initiatives with HIM, CDI, and Quality Departments. Utilizes knowledge gained from denials to guide ongoing documentation improvements.

4. Performs complex chart reviews for advanced CDI topics and serves as a mentor to staff on such cases. May include quality reviews (HACs, PSIs, Mortality, etc.), DRG pre-billing opportunity reviews, or to identify/resolve denials risk.

5. Takes a case assignment as deemed necessary by the CDI Manager during times of high census, PTO or short staffing. Monitors and assists with team case assignments to ensure accurate case coverage per organizational needs.

6. Formulates credible and compliant queries, meeting industry and organizational standards to capture the patient’s complexity of care, appropriate financial reimbursement and quality outcomes.

7. Remains current with clinical and coding knowledge and documentation requirements; serves as a subject matter expert. Assumes responsibility for professional development and ongoing professional education.

8. Identifies and provides feedback to manager on optimization of workflow processes.

9. Adheres to all Northwest Community Hospital standards, policies, and procedures.

1. Graduate of an accredited school of nursing, Health Information Management program or foreign medical graduate required. Bachelors required or foreign medical graduate.

2. Licensed RN, HIM credential, CCS or CCDS required.

3. Minimum of three years of recent inpatient clinical documentation improvement experience.

4. Prior leadership experience preferred.

5. The interpersonal skills to work with all levels of internal and external customers.

6. The communication skills to deliver presentations involving complex issues to a wide audience. Excellent written and verbal communication.

7. The ability to be diplomatic and negotiate, with strong conflict management skills.

8. The organization and planning skills necessary to work independently and effectively manage time.

9. The business acumen to be self-directed, apply critical thinking skills and creative problem solving within a fast paced environment.

10. Ability to analyze data to drive performance.

11. The ability to project a professional image that is consistent with the NCH value of Customer Focus.

12. The technical skills and willingness to learn computer applications relative to position such as MS PowerPoint, Excel, etc.

PHYSICAL REQUIREMENTS:
1. Requires light physical effort. May require frequent periods of standing or walking.
2. May require frequent lifting or moving of lightweight material, occasional moving or lifting of average weight materiel, rarely lifting or moving of heavy weight material.
3. The flow of work and the character of duties requires normal mental and visual attention much or all of the time.
WORKING CONDITIONS:
1. Conditions are acceptable. At least one disagreeable element or hazard (ie.infectious disease) is frequently present in the environment while several disagreeable elements or hazards are occasionally present.

About Northwest Community Healthcare

In January 2021, Northwest Community Healthcare (NCH) joined NorthShore University HealthSystem, which is now NorthShore – Edward-Elmhurst Health. The NCH Arlington Heights campus features a 509-bed hospital with a Level II Trauma Center, Level III Neonatal Intensive Care Unit and a dedicated pediatric acute care center. Throughout the northwest suburbs, NCH has 23 doctor’s offices; five immediate care centers; seven physical rehabilitation sites; and 13 lab locations.

NorthShore – Edward-Elmhurst Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties. Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals – Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) – all recognized as Magnet hospitals for nursing excellence. Located in Naperville, Linden Oaks Behavioral Health, provides for the mental health needs of area residents. For more information, visit NorthShore.org, SwedishCovenant.org, NCH.org and EEHealth.org.