The Clinical Documentation Improvement (CDI) Educator provides system-wide education and training to CDI staff, medical providers and ancillary staff on effective, compliant clinical documentation and processes. This role facilitates consistent, accurate, optimal documentation by providing both formal and informal educational programs. The CDI Educator assists in the development, implementation, and coordination of system-wide formal CDI orientation and ongoing education programs, including competency standards. The incumbent will work with the analytic team, leadership and the coding department to assess documentation gaps and formulate appropriate CDI educational tools to include, but not limited to, power point presentations, memos, and documentation tips sheets that enhance knowledge and result in appropriate documentation capture of patient condition, complications, and comorbidities.
The CDI Educator will apply teaching/learning principles in establishing an overall educational program related to effective clinical documentation for, and in collaboration with, CDI staff, physicians and the health care team. This associate will provide education for all members of the patient care team on issues relating to clinical documentation. Also, the CDI Educator will act as a resource to the CDI team, Coding Integrity, Clinical Appeals Team, Compliance, and clinical providers on optimal clinical documentation.
- Develops, implements and maintains formal and informal educational programs, including creating the CDI orientation program, documentation improvement opportunities, coding and reimbursement issues, as well as performance improvement methodologies for internal customers and physicians.
- Analyzes and compiles accurate and complete data for statistical reporting and educational presentations, as needed.
- Communicates and interacts with physicians and clinical staff via informal verbal communication, the use of written communication tools, and formal educational presentations.
- Utilizes research, analytic data and observations to provide recommendations to improve the overall quality and completeness of clinical documentation.
- Analyzes, summarizes, and documents outcomes of documentation improvement process for re-evaluation of ongoing program revisions.
- Participates as a member of work groups related to clinical documentation, utilization and compliance, as needed.
- Establishes cooperative and multidisciplinary relationships with physicians, coding staff and other health team members.
- Acts as a resource to the CDI department and health team members related to optimal documentation, educational needs and successful problem resolution.
- Familiarity with MS-DRG/APR-DRG's and Inpatient Prospective Payment System (IPPS), including new CMS guidelines regarding key elements including clinical documentation of what constitutes an inpatient admission. In addition, possesses skills to effectively communicate the use various coding systems and Official Coding Guidelines.
- Performs concurrent and retrospective reviews of the medical record utilizing evidence-based knowledge, protocols and criteria. Facilitates modifications to support clinical documentation of health team members to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a focus on physician documentation, inpatients and DRG payers.
- Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
- Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart.
- In conjunction with CDI leadership, tracks response to clinical documentation and trends in CDI metrics.
- Maintains and enhances current medical, coding and CDI knowledge by participating in continuing education offerings.
- Effective ability and willingness to communicate benefits of complete and accurate documentation to physicians relating to their daily practice of medicine.
- Bachelor's degree in Nursing, Masters preferred.
- Will consider a physician; physician assistant; or a Nurse Practitioner if knowledgeable of clinical documentation.
- 3-5 years' experience in an acute hospital setting.
- 3-5 years' experience as a clinical documentation specialist
- 2-5 years' experience in formulating and presenting for education to physicians and clinical staff
- Experienced educator with a strong understanding of the requirements for clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payers preferred.
- Auditing experience strongly preferred
C. Licenses, Registrations, or Certifications
- Current on license according to state and federal requirements if applicable.
- Certified Clinical Documentation Specialist (CCDS) issued by the Association of Clinical Documentation Improvement Specialists (ACDIS) or Certified Documentation Improvement Practitioner (CDIP) issued by The American Health Information Management Association (AHIMA).
- ICD training certification.
- CCS strongly preferred.