Position Highlights:

Position: Lead CDIHourly Pay Rate: $46.79-$72.52/hour. The hourly pay rate offered is determined by a candidate’s expertise and years of experience, among other factors.Location: Warrenville, ILFull TimeHours: Monday-Friday, [hours and flexible work schedules]Hybrid

Position Overview:

The Lead Clinical Documentation Integrity (CDI) Specialist reports to the Director 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.

What you will do:

Medical Record Reviews

Review medical records concurrently to ensure accuracy, completeness, and specificity of clinical documentation. Identify and clarify missing, conflicting, or nonspecific physicians’ documentation through queries and follow up. Collaborate with healthcare providers to ensure accurate and comprehensive documentation of patient diagnoses and treatments.

Query Management and Compliance

Develop and implement effective query  to resolve  documentation issues. Ensure queries are clear, concise, and compliant with industry’s standards and regulatory requirements. Track and follow up on outstanding queries to ensure timely responses. Query format and questions meet AHIMA and ACIDS guideline. Ensures adherence to professional standards, quality standards, licensure, and federal laws.

Quality

Ensure clinical documentation complies with all applicable regulations and standards, including those set by CMS, Joint Commission, and other governing bodies. 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.

Physician Collaboration and Education

Provide education to the physicians and other clinical staff on documentation best practice and importance of accurate clinical documentation.

Professional Development

Attend education programs, workshops, and one-one-one training to enhance continuous learning. Participate  in professional organization such as the Clinical Documentation Improvement Specialist (ACDIS) or the American Health Information Management. Actively engage in mentoring relationships to support less experienced colleagues and contribute to professional development  within the team.

Other Duties as Assigned

Takes a case assignment as deemed necessary by the CDI Director during times of high census, PTO or short staffing. Monitors and assists with team case assignments to ensure accurate case coverage per organizational needs. Identifies and provides feedback to the Director on optimization of workflow processes. May include but not limited to special projects related to Revenue Cycle or  Endeavor System workflow, process improvement or task forces.

What you will need:

Education: Associate in nursing or HIM is required or Bachelor’s degree in nursing is preferredLicense/Certifications: Nursing or RHIT, IL Licensed RN Preferred. CCDS or CCS RequiredExperience: Minimum of (3) years of recent inpatient clinical documentation specialist experience. 3-5 years RN experience current Acute Care Hospital (critical care preferred). 3-5 years HIM with CDI experience       

Benefits:

Career Pathways to Promote Professional Growth and DevelopmentVarious Medical, Dental, and Vision optionsTuition ReimbursementFree Parking at designated locationsWellness Program Savings PlanHealth Savings Account OptionsRetirement Options with Company MatchPaid Time OffCommunity Involvement Opportunities

Endeavor 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. For more information, visit www.endeavorhealth.org.  

When you work for Endeavor Health, you will be part of an organization that encourages its employees to achieve career goals and maximize their professional potential. Please explore our website (www.endeavorhealth.org) to better understand how Endeavor Health delivers on its mission to “help everyone in our communities be their best”. 

Endeavor Health is committed to working with and providing reasonable accommodation to individuals with disabilities. Please refer to the main career page for more information. Diversity, equity and inclusion is at the core of who we are; being there for our patients and each other with compassion, respect and empathy. We believe that our strength resides in our differences and in connecting our best to provide community-connected healthcare for all.

EOE: Race/Color/Sex/Sexual Orientation/ Gender Identity/Religion/National Origin/Disability/Vets, VEVRRA Federal Contractor.