• Review session notes completed by RBTs and BCBAs for accuracy, completeness, and compliance • Identify missing information, inconsistencies, or documentation errors • Ensure clinical notes meet required standards for insurance billing • Provide clear, respectful, and constructive feedback to clinicians • Communicate areas of concern with professionalism and emotional intelligence • Track and follow up on corrected documentation where necessary • Maintain organized and accurate records of quality reviews • Collaborate with internal and clinical teams to support documentation standards

• Manages the CDI staff: Management of daily activities of the Clinical Documentation Specialist (CDS) team: schedules staff; provides work direction and training/mentoring; ensures timely completion of assignments and performance evaluations. • Validates and improves quality of query activities; provides feedback to the director on operational concerns; provides feedback to Physician Advisors on provider response issues; assists with physician in-services as needed. • Reviews and analyzes data and reports to evaluate progress and helps initiate process improvements. Reports updates and team progress to appropriate committees. • Works closely with the Coding and CDI staff to resolve discrepancies between working and final DRGs, and coordinates efforts with coding/HIM/UR and other departments to ensure the coded record reflects the acuity of patients and level of provider care. • Develops and implements on-going CDI nurse and physician education and training programs to solve coding and documentation issues. • Acts as leadership resource for the team; supporting, fostering and assuring the continued professional development of group/individual skill sets and competencies. • Assists with departmental budget annually as requested by QI Director

• Oversee day-to-day CDI functions, including daily assignments and department-wide tasks, and escalates recommendations to the CDI Manager for adjustments to workflow when necessary. • Coordinate staff schedules to meet service level expectations. • Escalate inconsistencies in CDI operations that do not align with corporate standards. • Make recommendations for the development of CDI resources and policy and procedure development based on observations with staff. • Participate in problem identification, perform root cause analysis, and recommend a solution to CDI Management.

• Provides concurrent and subsequent reviews of the clinical documentation in the medical record using documentation improvement guidelines. Evaluates and identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure overall quality and completeness of the record. The key responsibility is to review the chart for information not currently in the chart but supported by clinical indicators; then queries the medical staff when necessary through written or verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality. • Performs a thorough chart review to determine the most appropriate principal diagnosis of the patient. • Performs a thorough chart review to identify co-morbidities/complications and documents these appropriately within the concurrent CDS worksheet. • Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses. • Coordinates with coding/HIM/UR and other departments to ensure the coded record reflects the acuity of patients and level of provider care. • Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization. • Maintains the ability to be flexible and prioritizes daily responsibilities. • Uses strong and professional communication skills with providers to clarify information in the medical record. Uses appropriate and compliant querying tools (templates) to capture needed documentation. Conducts follow-up on unanswered queries during the patient stay to obtain a response to unanswered queries. • Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or individually with physicians. • Reviews the progress of the CDI program by interpreting performance, process, and quality ratings reports. Identifies areas of focus through report analysis. • Experience with CDI for Peds, Neonatal, and OB.