Role Description Identifies documentation problem areas and creates audits directed at monitoring performance improvement in these areas. Obtain pre-certification for clinical areas and any home care needs. Provides assistance with pre-certification for inpatients that require testing as outpatients. Responsibilities - Studies existing agency policies and interviews agency personnel to evaluate effectiveness of quality improvement programs. - Facilitates all policies and procedures applicable to documentation process. - Develops educational materials to educate team members. - Compiles statistical data and creates reports summarizing audit findings as requested. - Coordinate initiation of authorization for testing for inpatients and obtain authorization for transport services for patients being transferred to another facility or home. Qualifications - High School Diploma or GED - Associate's Degree (preferred) - Licensed Practical Nurse (preferred) - RN (preferred) Requirements - Experience: Less than 2 years - Supervisor Experience: No Experience Benefits - Comprehensive medical, dental, vision, life insurance, and legal services available first day of the month after hire date - Disability insurance paid for by BJC - Annual 4% BJC Automatic Retirement Contribution - 401(k) plan with BJC match - Tuition Assistance available on first day - BJC Institute for Learning and Development - Health Care and Dependent Care Flexible Spending Accounts - Paid Time Off benefit combines vacation, sick days, holidays and personal time - Adoption assistance

• Provides onsite and remote clinical documentation integrity (CDI) support to the Health Ministry (HM) CDI programs as part of the System Office CDI Float Pool. • Utilizes advanced coding and/or clinical expertise to direct efforts toward the improvement and integrity of clinical documentation. • Responsible for reviewing and/or auditing medical record clinical documentation to support the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services rendered to all patients. • Audits HM CDSs for query compliance, workflow and missed documentation opportunities. • Trains end users in the use of CDI system software, standards, and workflow. • Demonstrates understanding of and facilitates appropriate clinical documentation to ensure that the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services provided are accurately reflected in the health record. • Conducts clinical documentation chart reviews and queries providers as appropriate to support RHMs staffing needs. • Reviews may be conducted on site or remotely. • Follows HM CDI Program workflow and processes and communicates with local CDI Team to support local operations. • Communicates with physicians and other members of the healthcare team at the HM regarding clinical documentation as part of local CDI Team assignment. • Audits medical records, queries, CDS and coder assigned codes, CDI software entries, etc., as requested to provide feedback to the HMs for improvement opportunities. • Trains end users in the use of CDI system software, standards, and workflow. • Provides documentation education to providers and members of healthcare team at the RHM as part of CDI Team assignment or as requested. • Demonstrates ability to quickly learn and master the various CDI technology applications, systems and workflows in place across the enterprise. • Provides expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgment and serves as a professional role model by demonstrating desirable practice behaviors. • Assists the System Office Clinical Documentation Manager with all aspects of the CDI program across the system including data collection and maintenance of the CDI Dashboard. • May develop educational content for providers and CDSs on CDI workflow and processes, CDI and Physician software systems, and documentation and coding guidelines as requested. • Performs other duties as assigned by leadership.

• Implements and continuously develops onboarding for all new Clinical Documentation Specialists (CDSs) for mentoring and education needs. • Leads and coordinates training of new CDI staff. • Collaborate with CDI leadership and other clinicians to facilitate the ongoing relevance of department specific orientation content, educational materials, and training programs/resources. • Formulates customized education to other healthcare professionals based on audience and areas of opportunity. • Audits CDSs as needed to ensure that system objectives are met. • Provides 1:1 mentoring as needed. • Oversees and coordinates SMART related education, meetings, and requirements for the department and as instructed by the SMART department.

• Review inpatient medical records for documentation accuracy, completeness, and compliance • Maintain an accuracy rate of 98% • Identify opportunities for clarification of diagnoses and procedures • Initiate compliant physician queries to clarify conflicting documentation • Collaborate with coding staff to ensure accurate coding and DRG assignment • Monitor documentation trends related to mortality and quality indicators • Conduct clinical validation reviews for high-risk conditions • Maintain productivity and quality standards • Participate in multidisciplinary rounds and documentation improvement initiatives