Clinical Documentation Education Lead
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Job Description
Clinical documentation education lead improving provider training and CDI accuracy. Supporting Georgia’s integrated health system through audits, queries, and documentation education.
Responsibilities:
- Collaborate with CDI leadership, coding teams, providers, auditors, and operational leadership to improve documentation and coding accuracy
- Assess provider and CDI team knowledge and skill gaps using data trends, CDI KPIs, audit results, industry events, and leadership needs
- Develop, tailor, and deliver live and recorded CDI education and training
- Train providers on documentation best practices and clinical documentation specialists on operations, skills, teamwork, customer service, and change management
- Conduct new employee orientations, skills development, and new-user technology training
- Create education materials, training materials, presentations, and meeting resources
- Provide timely follow-up education based on CDI and Coding audit results and query activity
- Assist with testing future CDI technology enhancements and function as a super user for CDI software and applications
- Review clinical documentation remotely during patient admissions
- Perform hospital-wide medical record reviews to improve completeness, accuracy, coding compliance, reporting, and patient outcomes
- Submit compliant electronic queries to clinicians and provide appropriate follow-up
- Escalate unanswered queries according to the Wellstar Query Escalation process
- Reconcile records daily in the Solventum/3M 360 Encompass CDI tool
- Review Coding Clinic changes and maintain current knowledge of coding, billing, medical terminology, procedures, medications, and diseases
- Participate in required meetings, conference calls, and stakeholder presentations
- Support regulatory compliance and departmental policies
- Perform other duties as assigned
Requirements:
- Associate's degree in Nursing, bachelor's degree in Health Science, accredited Health Science program, or Doctorate of Medicine
- Certified Clinical Documentation Specialist within 180 days of hire or Certified Documentation Improvement Practitioner within 180 days of hire
- Minimum 2 years working in an acute care setting as a Clinical Documentation Specialist (CDS)
- Minimum 5 years of healthcare experience
- Strong understanding of disease processes, clinical indications, treatments, and provider documentation requirements
- Knowledge of Medicare, Medicaid, and commercial payer coding and billing rules
- Familiarity with an encoder and current working knowledge of Coding Clinic Guidelines and federal updates to MS and APR DRG systems
- Expert knowledge/experience in Clinical Documentation Integrity, including productivity, quality, education and training, compliance auditing, data analysis and trending, report management, and performance improvement initiatives
- CDI/Coding chart review experience
- Excellent communication, presentation, problem-solving, time management, training, and peer development skills
- Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives
- Proficient computer skills in Microsoft Word, Excel, PowerPoint, and CDI technology tools
- Comfortable performing data analysis and preparing and maintaining records and written reports
- Ability to leverage technology and reporting capabilities to identify education opportunities
- RNs must be licensed, knowledgeable, and uphold nursing practice standards upon hire
- Non-clinical/coding candidates must have at least one active/current CCS, CPC, RHIA, or RHIT certification upon hire
Benefits:
- Virtual/remote work arrangement
- Supportive work environment
- Meaningful work in healthcare
- More rewarding life and employee support
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