Job Summary
The Lead Clinical Documentation Integrity Specialist is responsible for overseeing and assessing medical records to verify the precision, clarity, and adherence to regulatory requirements in documentation. This role also serves as a vital communication link between the medical personnel and the Clinical Documentation Improvement (CDI) team, addressing feedback, providing training, and resolving any documentation disputes.
Responsibilities
- Manage and evaluate medical documentation for accuracy and specificity.
- Ensure compliance with relevant regulatory guidelines.
- Serve as an intermediary between medical staff and the CDI team to enhance documentation practices.
- Facilitate training sessions and provide necessary feedback to improve documentation quality.
- Address and resolve conflicts related to documentation standards.
Qualifications
- A minimum of five years of experience in clinical documentation integrity.
- At least three years of clinical experience in a healthcare setting.
- A relevant educational degree in a healthcare-related field.
- Current licensure as a Registered Nurse (RN) or as a licensed medical provider.
- Certification as a Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) is required within two years of employment.
Adventist Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
