Clinical Document Specialist Lead

Atlanta, GA US

Job ID: 1702 Position Type: HIM

Lead Clinical Documentation Specialist

Our hospital believes in a team-centered approach in everything we do and every patient that we serve...we are recognized as a great place to work and grow professionally...

This is a great step up into a leadership role supervise CDS staff, oversee training, presentations at physician education meetings


  • The Clinical Documentation Specialist (CDS) Lead demonstrates natural leadership abilities and strong clinical knowledge and understanding of coding/DRG requirements to improve overall quality and completeness of clinical documentation in the patient medical record on a concurrent, and potentially a prospective and retrospective basis, using a multidisciplinary team process.
  • The CDS Lead supervises CDS staff, oversee training, presentations at physician education meetings, works collaboratively with physicians, other healthcare professionals and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate utilization, clinical severity, outcomes and quality is captured for the level of service rendered to all patients, as well as ensuring compliant reimbursement of patient care services.

Required Minimum Education:

  • Bachelor s degree in nursing or health-related field desirable.

Required Minimum Licensure/Certification/At least one of the following active certification/licensure required:

  • RN: Registered Nurse in the State of Georgia
  • CDIP: Clinical Documentation Improvement Practitioner
  • CCDS: Certified Clinical Documentation Specialist

Required Minimum Experience:

  • Minimum of five years of healthcare experience required, strong medical surgical background is preferred.
  • Experience with utilization management, coding/DRG, billing, auditing and various healthcare payers is also preferred.
  • Clinician preferred and/or CDIP/CCDS credential.
  • 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 Minimum Skills:

  • High level of interpersonal and communication skills necessary to establish rapport with physicians and other healthcare providers.
  • 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 preferred.
  • Regulatory background and DRG reimbursement knowledge preferred.

Please contact Ina Phillip at or 770-433-2220

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