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Clinical Documentation Lead

Wellstar Shared Services • Marietta, GA • Coding, Compliance, and Health Information Systems • 104602 • Days, Evenings, Weekend Option • Full-Time


The Clinical Documentation Improvement Lead Specialist demonstrates excellent problem-solving, clinical knowledge, and coding knowledge requirements to support and improve the overall quality and completeness of clinical documentation in the patient medical record on a concurrent basis supporting and using a multi-disciplinary team process. The CDI Lead Specialist works collaboratively with the CDI team members, physicians and coding team members to ensure that clinical information in the medical record is present and accurate so that the appropriate clinical severity is captured for the level of service rendered to all patients. The CDI Lead Specialist supports the Departmental goal by assisting the department and organization in achieving clinical and operational excellence in relation to Clinical Documentation Improvement efforts.


Core Responsibilites and Essential Functions

  • Specializes in 1) CDI Specialist Onboarding & Education, 2) In collaboration with physician partners, ensures physician education, or 3) Performs Audits. Assists management remotely with preparing provider education materials, gathering articles or other information for presentations and meetings. Performs staff, PSI, HAC, HAI, mortality, etc. reviews remotely as assigned by management.
    * Initiates gathering topics, preparing and providing regular CDI education to team members based on trends, industry events and based on management needs
    * Conducts new specialist onboarding and education
    * Reviews medical records concurrent to the patient stay to determine opportunities as it relates to clinical documentation improvement, PSI, HACs, mortality, etc.
    * Conducts and provide real-time audits of reviews, queries and reports and provide feedback on process, query opportunities and query compliance. Reviews data and trends to identify additional areas of opportunity.
    * Conducts Validation and Special Project tasks to support the CDI Manager/Director and ensure appropriate data is entered, captured and reported in the CDI Software for the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
    * Functions as a Super User with CDI Software and all other applications utilized in this position.
    * Assists with payroll as it relates to timekeeping duties as assigned by management
  • Reviews clinical documentation remotely during patient admissions to determine opportunities to improve physician documentation and communicates identified opportunities to the physician.
    * Reviews medical records concurrent to the patient stay to determine opportunities to query physicians regarding clinical documentation
    * Conducts follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart.
    * Performs concurrent hospital-wide medical record reviews facilitating improvement in the quality, completeness and accuracy of medical record documentation to ensure coding compliance, accurate reporting, and improved patient outcomes.
    * Submits electronic queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population.
    * Ensure queries are compliant, grammatically correct, concise and free of typographical errors.
    * Provides appropriate follow up on all queries.
    * Notifies onsite Regional CDI Manager immediately when queries are not answered. Provides all data necessary for onsite Regional CDI Manager to assist.
    * Reconciles all appropriate records daily in CDI software tool to ensure appropriate reporting is generated.
    * Maintains required daily/weekly/monthly metrics. Meets productivity standards.
    * Participates in required onsite meetings, conference calls and Skype presentations.
    * Adheres to departmental Policies and Procedures.
    * Participates in assuring hospital compliance with Federal and State regulatory requirements.
    * Submit ideas to improve work flow and increase productivity of his/her team to the CDI Regional Manager/Executive Director and perform any other duties as assigned.
  • Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement.
    * Participates in assuring hospital compliance with Federal and State regulatory requirements.
    * Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process.

  • Required for All Jobs

  • Performs other duties as assigned
  • Complies with all WellStar Health System policies, standards of work, and code of conduct.

  • Qualifications

    Required Minimum Education

  • Bachelor's Degree in nursing or other health-related field Required

  • Required Minimum Experience

  • Minimum 2 years Clinical Documentation Specialist Required and
  • Minimum 7 years healthcare experience, strong medical surgical and/or critical care background Preferred and
  • Minimum 5 years as a Clinical Documentation Specialist Preferred and
  • Experience with utilization management, coding, billing, auditing and various healthcare payers Preferred and
  • Clinician and/or CDIP/CCDS credential Preferred and
  • It is expected that all RN?s are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association Required

  • Required Minimum Skills

  • High level of written communication skills necessary to establish rapport with physicians, other Team members, coding team and all other customers as applicable. Excellent time management, training and peer development skills.
  • High level of motivational and interpersonal skills.
  • Strong written and verbal communication skills, decision-making and analytical skills, advanced computer skills and ability to work well under pressure individually and as part of a team.
  • Minimum MS Office (Word, Outlook, Excel and PowerPoint) knowledge and expertise is expected.
  • Chart review experience required.
  • EPIC Electronic Medical Record and CDI Software experience is preferred.
  • Regulatory background and DRG reimbursement knowledge and strong understanding of coding methodologies and guidelines preferred.

  • Required Minimum License(s) and Certification(s)

  • Reg Nurse (Single State) 1.00 Required 1.00
  • RN - Multi-state Compact 1.00 Required 1.00

  • Additional Licenses and Certifications

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