• Use clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of inpatient medical records • Evaluate the documentation of clinical services by identifying opportunities for improving the quality of medical record documentation • Facilitate and obtain appropriate physician documentation for clinical conditions or procedures • Participate in ongoing documentation improvement initiatives and education plans

Role Description The CDIS will facilitate modifications to clinical documentation through extensive concurrent chart review and interactions with physicians and other clinicians to ensure: - Accurate documentation of diagnosis and procedures - Reflection of appropriate clinical severity - Clarification of complications and conflicting documentation - Capture of co-morbid conditions The CDIS will complete the majority of concurrent reviews to evaluate selected patient's medical records for overall quality and completeness. Education of physicians, non-physician clinicians, nurses, and coding staff on an ongoing basis regarding: - Documentation opportunities - Coding and reimbursement issues - Relevant quality and performance improvement opportunities Assist team in meeting and exceeding high performing CDI program metrics. Qualifications - Clinical candidates: Licensed as a Registered Nurse with an Associate Degree (ADN) or Bachelor’s degree in Nursing (BSN), or an MD - At least three (3) years of recent acute care nursing experience required. ICU or ED experience preferred. Clinical expertise required. - HIM professional candidates: Credentialed as an RHIA, RHIT, CPC, or CCS and have experience in ICD 10 coding. - At least three (3) years of clinical coding and/or auditing experience in a hospital environment. - Computer PC literacy required. - Must be an excellent communicator, negotiator, and have great organizational skills. - Strong knowledge of clinical documentation guidelines required. - Must be able to work collaboratively and independently. - Must be flexible with responsibilities in order to meet departmental needs. - Must be able to demonstrate initiative and the ability to work in a fast-paced environment with proficiency in multi-tasking and prioritization. - Experience in computerized hospital/health information management systems and software applications are required. Requirements - Utilize extensive knowledge of documentation requirements and guidelines in accordance with Coding Clinic to improve the overall quality and completeness of clinical documentation by performing concurrent stay reviews. - Utilize client technology to track documentation notes and observations, assign Working DRG and calculate Query DRG to reflect the impact of queries initiated, complete query entry for tracking purposes, and complete validation process to ensure diagnosis located in EMR or attained by query are final coded. - Educate internal staff on clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and conduct follow-up reviews of clinical documentation to ensure points clarified with the physician have been recorded in the patient’s record. - Follow established workflows and processes developed for Clinical Documentation Integrity, Strategic Source. - Compose and initiate AHIMA compliant queries. - Maintain open communication with coding to discuss DRG assignment, diagnosis, clinical indicators, coding clinics, and guidelines and educating each other on specialty. - Assign Working DRG for Case Management department to view Length of Stay (LOS) of patients. - Participate and provide input regarding CDI program activities, and attendance at routine team meetings. - Maintain current skill set with regard to government regulations, compliance, and reimbursement guidelines. - Expected to keep abreast of new legislation and regulations that affect CDI. - Maintain personal and professional education and growth. - Responsible for maintaining continuing education credits as required by credentialing organization. Benefits - Salary range for this role is from $85,000.00 to $90,000.00, varying based on geographic location, candidate experience, applicable certifications, and skills. Company Description SAVISTA is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, age, veteran status, disability, national origin, sex, sexual orientation, religion, gender identity, or any other federal, state, or local protected class.

• Plan, develop, and implement clinical documentation education programs for CDI specialists and providers • Develop orientation and onboarding program for CDI team • Educate team members on review functions within CDI program • Create annual education based on coding and documentation updates • Collaborate with healthcare professionals for program goals and documentation • Mentor and train CDI staff • Monitor and evaluate documentation for compliance and accuracy

• The Director of Clinical Documentation Integrity demonstrates a high level of clinical proficiency and critical thinking skills necessary for oversight and success of the CDI solution. • Works collaboratively with Guidehouse and facility CDI leadership team to meet contractual obligations, achieve best practice CDI metrics and assist in meeting overall organizational goals related to documentation improvement. • Must demonstrate ability to design and manage process and workflow improvements, system implementations and project management. • Will assist in analyzing, tracking, trending and reporting CDI and/or organizational data and metrics. • Collaborate extensively and in a collegial manner with Physician Advisors, Chief Medical Officer (CMO), Chief Quality Officers (CQO’s), other key providers and client site Department leaders. • Actively participates on committees and presents at the monthly revenue cycle meetings to demonstrate solution performance and improvement in clinical documentation.