Lead Clinical Documentation Specialist - CDI - CDS

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Provide day-to-day oversight of Clinical Documentation Specialists at Care Site, conduct chart reviews functioning as a CDS and responsible for providing education to CDS and providers.

  • Lead and coordinate the day-to-day activities of the Clinical Documentation Integrity (CDI) operations at the care sites. Oversee individual CDS workload/assignments. Monitor reporting time/timeliness. Serve as a resource for internal customers and Clinical Documentation Integrity Specialists (CDSs).
  • Assist in implementing new SCL Health CDI policies and procedures related to CDI and coding guidelines. Accountable for dissemination of all facility-specific and CDI-specific information to CDSs and adherence of CDSs to requirements.
  • Assist with planning and leading of Care Site huddles.
  • Assist with planning and leading CDS peer review activities.
  • Serve as 2nd level reviewer for all cases with unanswered queries being considered for escalation to Physician Champion/CMO, and aid in the escalation as appropriate for the case.
  • Act as a CDI liaison for other Care Site disciplines to facilitate coordination and collaboration as needed to achieve goals (for example, Case Management, UR, Nursing, Wound Care, dieticians, etc.).
  • Assist with quality assurance activities for the Care Site and CDI department as directed by CDI Leadership. Audit work of CDSs for accuracy, productivity and quality standards. Proactively identify issues or trends, and propose solutions.
  • Communicate issues or concerns with site CDI operations to system CDI Leadership.
  • Arrange and deliver education for providers and care givers based on identified opportunities. Educational content is done through collaboration with System CDI Educator/Manager and Care Site CDI team.
  • Serve as a mentor and subject matter expert to new CDS associates.
  • Assist CDS Manager in evaluation of care site CDSs – participate in performance improvement/action plan activities as needed to assure all CDSs are meeting or exceeding performance expectations.
  • Work 50% of time as Clinical Documentation Specialist reviewing charts and work with providers for improved documentation unless approved otherwise by CDI Manager or Director.
  • Participate in continuing education programs to maintain an understanding of anatomy, physiology, medical terminology, disease processes and surgical techniques to support the effective application of coding guidelines to inpatient diagnoses and procedures.
  • Enhance professional growth and development through participation in professional organizations, coding roundtables, literature reviews, and relevant workshops.
  • Promote the mission, vision, and values of SCL Health, and abide by service behavior standards.
  • Perform other duties as assigned.


Required: Bachelor’s Degree in Nursing, Health Information Management, or related field is required.


Certification, Licensure, Registration:

Preferred: RN

CDIP or CCDS certification required or will achieve within 1 year of eligibility.



  • Ability to deal with conflicting interests and to resolve situations effectively.
  • Ability to effectively communicate, both orally and in written form, with people at all levels of the organization, including Senior Leadership.
  • Possess strong clinical and critical thinking skills.
  • Proficient computer skills necessary in order to perform the tasks required, including intermediate knowledge of databases and spreadsheet applications required (Excel).
  • 3M CDIS preferred or ability to learn.

Organization: Corporate, Various Locations
Primary Location: MT-Billings/Surrounding Areas-Billings
Department: SYS-Clinical Doc Improvement
Schedule: Full-time
Shift: Day Shift
Job Posting: 5/17/2017 11:02:35 PM
FTE: 1.0
Job Number: 16004946
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