Summary: The Clinical Documentation Specialist (CDS) II conducts concurrent, comprehensive reviews of clinical documentation within the medical record to achieve accurate and detailed documentation. The CDS will regularly communicate with providers for clarification of documentation through querying. The CDS will also be responsible for educating providers about the program and how to improve their documentation through daily conversations as well as formal classroom presentations.

　　As the Lead the CDI II Specialist will take on the following additional responsibilities:

　　Train new CDI staff, monitor their work and provide weekly updates.

　　Review team’s work for consistency and quality.

　　Assigns daily worklist within their team

　　Attends meetings on software improvement and product updates, CDI program review and updates

　　Communicates with physicians and provide one on one education

　　Prepares prebill reports for review

　　Prepares account lists for escalation

　　Shares and distributes worklist assignments when a team member calls outs

　　Tracks team performance and reports when needed

　　Licensure: Must have either a Registered Nurse (RN) license, medical license, or license in a related field. Certified Clinical Documentation Specialist (CCDS) Required. Certified Clinical Documentation Improvement Practitioner (CDIP) Optional. Certified Coding Specialist (CCS) Required.

　　Experience: Minimum of 2 years of experience with clinical appeals. Minimum of 5 years of experience in practical CDI work in an inpatient setting.

　　Skills and Abilities:

　　Must display teamwork and commitment while performing daily duties

　　Must demonstrate initiative and discipline in time management and medical record review

　　Recognize opportunities for documentation improvement

　　Strong Verbal Communications Skills

　　Strong Written Communications Skills

　　Excellent Interpersonal Skills

　　Computer skills: Excel, PowerPoint, MS Word - Intermediate Level

　　Excellent Organizational Skills

　　Demonstrates knowledge of Official Coding Guidelines and the DRG Classification System to insure compliance with such regulations as they relate to the CDI function

　　Excellent organizational skills for initiation and maintenance of efficient workflow

　　Knowledge of coding compliance and regulatory standards

　　Understand pathophysiology of disease processes and their management.

　　Demonstrate knowledge of and perform the duties in accordance with the ethical and legal compliance standards as set by hospital policies and procedures, State and Federal Quality Improvement Organizations, Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS). 14. Understand clinical appeal process including the various levels for the major payors (Medicare, Managed Care etc) and be able to draft credible appeals to address such denials.

　　Demonstrate knowledge of resource management in an effort to decrease resource consumption while adequately maintaining effective operations

　　Working Conditions, Physical Environment and/or Safety Requirements : Work is performed in a standard office environment.