Lead Clinical Document Specialist, RN

Atlanta, GA 30301 US

Position Type: HIM Job Number: 1702

Job Description

Registered Nurse, RN Lead Clinical Documentation Specialist/CDI

  • Our health system is progressive and well respected and believes in a team-centered approach to 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 RN CDS staff
  • Oversee training
  • Give presentations at physician education meetings…

Overview for Registered Nurse, RN Lead Clinical Documentation Specialist/CDI:

  • The Lead RN Clinical Documentation Specialist (CDS) demonstrates 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 Lead RN CDS 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.

Minimum Licensure/Certification for CDI Specialist:

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

Minimum Experience:

  • Minimum of five years of healthcare experience required, strong medical-surgical/critical care background.
  • Experience with utilization management, coding/DRG, billing, auditing and various healthcare payers is also preferred.
  • High acuity clinician preferred and/or CDIP/CCDS credential.

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 360 Software experience are preferred.
  • Regulatory background and DRG reimbursement knowledge preferred.

We are actively interviewing and I look forward to sharing more details with you about this exciting growth opportunity!

Please click Apply and be sure to upload your resume so that you can be considered. Ina Phillip will contact all qualified applicants.

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