Clinical Documentation Lead (Technology)
Wellstar Health Systems

Facility: VIRTUAL-GA

Job Summary:

The Clinical Documentation Integrity (CDI) Technology Lead is a highly skilled and professional problem-solver, with strong clinical and coding knowledge, and analytical abilities, who will maintain CDI department's effectiveness an efficiency by optimizing CDI and provider workflows and technology for accurate documentation and coding. The CDI Technology Lead must know how to use Solventum/3M 360 Encompass, Epic EMR, and other CDI technologies to help with research and testing. The CDI Technology Lead will design, test, and implement strategies to improve technology software for the users, as well as perform validation and special project tasks to support the CDI Leadership and ensure accurate and complete clinical data entry, capture and reporting in the CDI software(s) for measuring and reporting physician and hospital outcomes. The CDI Technology Lead will communicate and train all the affected stakeholders about changes, upgrades, and system improvements on a regular basis, including the CDI and coding staff, providers, clinical informaticists, etc.

This is a Leadership Job

Core Responsibilities and Essential Functions:

1. Ensures the current CDI and provider workflows and technology are being optimally leveraged for

accurate clinical documentation and coding reviews and achieve strategic goals.

a) Evaluates how CDI and provider workflows and reports are impacted by Epic and Solventum/3M

360 Encompass enhancements and upgrades and reports the CDI Leadership team

recommendations, impacts and leads activities to successful implementation

b) Develops the design, testing, and implementation plans to enhance the software technology for the

users during update and upgrade periods to ensure they operate correctly and efficiently.

c) Creates and conducts the test scripts for the CDI technology improvements and updates, and

collaborates with relevant partners, such as the CDI and coding teams, providers, clinical informatics

team, etc.

d) Assists CDI Leadership team with exploring and testing of future technology improvements to

enhance CDI and provider workflows for accurate documentation and coding and improve

departmental efficiency and effectiveness.

e) Coordinates metrics of success for technology optimization and implementation

f) Prepares training materials for technical changes for CDI team and providers, collecting articles or

other information for presentations and meetings.

g) Provides education and training to CDI team and providers on how the user workflows are affected

by enhancements and upgrades.

h) Works with CDI Leadership team to identify and recommend enhancements to workflow and

technology use to boost CDI outcomes, using methods such as shadowing CDI staff, analyzing data

and trends to identify more areas of improvement, etc.

i) Functions as a Super User with CDI Software and all other applications utilized by the CDI team.

j) Participates in new user training on technology tools as needed

k) Performs any other duties as assigned

2. Reviews clinical documentation remotely during patient admissions to maintain CDI department's

effectiveness and efficiency by optimizing CDI workflows and technology for accurate documentation 10%

and coding. 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) Participates in required meetings, conference calls and presentations to the stakeholders, including the CDI staff, providers, clinical informaticists, etc. h) Adheres to departmental Policies and Procedures. i) Implements ideas to improve workflow and increase productivity/efficiency of the CDI team by collaborating with the CDI Leadership Team.

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 incorporate the impact of changes to documentation and coding

guidelines in the CDI workflows on an on-going basis.

Job Titles Reporting to this Job:

Trust/Engagement:

a. Builds a culture of trust and engagement as reflected in the Great Place to Work Trust Index Survey at a direct report, workgroup and hospital/entity level.

b. Holds leaders accountable for behaviors that create trust and engagement.

c. Performs all duties and responsibilities of this position in a manner that reflects the values of WellStar.

d. Maintains and strengthens relationships with physicians and assures their involvement in developing systems to assure the growth of the service and the cost-effective delivery of quality patient care in a manner that fosters patient and employee satisfaction.

Results Oriented Leadership:

a. Sets challenging and productive goals for team.

b. Holds team accountable for actions while providing leadership and motivation.

c. Provides resources and support,

d. Uses checkpoints and data to track progress, setting up system and processes to measure results.

Collaboration and Partnership:

a. Works collaboratively and as a team member with hospital leadership. Partners with Human Resources to achieve desired organizational culture, staffing and workforce metrics.

b. Fosters positive working relationships between staff and physicians across the Health System.

c. Fosters a culture that focuses on patient satisfaction, safety, customer service, staff participation, collaboration, motivation, and effective communication.

Required Minimum Education: One of the following:

• Associate's degree in nursing

• Completed degree from an accredited medical school

• Associate's or Bachelor's degree in a healthcare-related program

Required Minimum Licensure/Certification: For all candidates, one of the following certifications is required within six months of hire date:

• Certified Clinical Documentation Specialist (CCDS) from ACDIS

• Clinical Documentation Improvement Practitioner (CDIP) from AHIMA

Additional Certification Requirements: For candidates with a non-clinical background: at least one of the following active/current certifications is required:

• Certified Coding Specialist (CCS) from AHIMA

• Certified Professional Coder (CPC) from AAPC

• Registered Health Information Administrator (RHIA) from AHIMA

• Registered Health Information Technician (RHIT) from AHIMA

For candidates with nursing background, a current/active RN license is required.

Preferred Licensure/Certification:

• Epic certification is preferred

• For candidates with a clinical background, an active/current coding credential from AHIMA and/or AAPC is preferred

Required Minimum Experience:

• Two or more years working in an acute care setting as a Clinical Documentation Specialist (CDS)

• Minimum of five years of healthcare experience required

Preferred Experience:

• Prior technology experience with Solventum/3M 360 Encompass, Epic EMR, and/or other technologies related to CDI workflows is preferred

• Prior experience of working in inpatient case management or utilization review is preferred

Required Minimum Skills:

• 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 required

• Advanced knowledge of operating systems with the ability to create effective testing and production environments

• Strong technical and educational support skills

• Excellent communication skills, employing tact and effectiveness

• Demonstrate effective communication skills and collaborates with medical staff, clinical informatics, IT, CDI and coding teams, and other key stakeholders • 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

• Drives optimal use of the CDI technology tool and reporting capabilities to identify opportunities for workflow automations and efficiency gains

• Excellent time management, training, and peer development skills