Clinical Documentation Improvement Lead RN/Registered Nurse- Clin Doc Imp
The RN/Registered Nurse/RN in this role will be following established policies, procedures and professional guidelines coordinates the prioritization and oversees the day-to-day workflow of the Clinical Documentation Improvement (CDI) staff and provides Clinical Documentation Improvement expertise. This position is for an experienced CDI Specialist RN/Registered Nurse who works in partnership with the CDI Manager and Physician Advisors to ensure high quality and production standards are met. This will be accomplished through data evaluation, direct observation and review of medical records, and daily staff communication. This position is responsible to maintain concurrent and retrospective review expertise to ensure accuracy, specificity, and severity captures are obtained consistently by all reviewers. This position will also resolve CDI-Coder DRG discrepancies working in collaboration with the CDI Physician Advisors and Coding Supervisor. This position will also participate in various projects and initiatives within the CDI Department. Participates in the education and onboarding process of all new hires. Performs duties and conducts interpersonal relationships in a manner promoting a team approach and collaborative work environment with physicians, CDI staff and coders.
Bachelors degree in Nursing or Master’s degree in Nursing required.
2 years of clinical RN experience in acute care required.
Currently licensed to practice as a registered nurse by Pennsylvania Board of Nurse Examiners required.
2 years of experience as a Specialist Clinical Documentation Improvement required.
2 years of ICD-10-CM/PCS coding experience required.
CCDS, CDIP or CCS required or ability to obtain within 6 months of employment in the role.
KNOWLEDGE, SKILLS, & ABILITIES:
Advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting required.
Ability to analyze, produce and present high level analysis and metrics required.
Proficient computer skills to include all components of Microsoft Office suite required.
Project management and research skills required.
Training and development background with previous experience with educational platform development and presentation preferred.
Previous supervisory experience preferred.
Masters degree in Nursing preferred.
If chosen for this position, you may be required to pass a Post Offer Employment Physical Exam in accordance with the measurements listed in the Work Task Analysis (WTA) report. This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position. All individuals (including current employees) selected for a position will undergo a background check appropriate for the position’s responsibilities.
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