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Clinical Documentation Lead

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The Clinical Documentation Lead provides day-to-day oversight of Clinical Documentation Specialists (CDS) at Care Site, conducts chart reviews functioning as a CDS and responsible for providing education to CDSs and providers. Serves as the CDI Subject Matter Expert and go-to person for internal customers and CDSs.

The Clinical Documentation Specialists will work in a 100% electronic system with EPIC and 3M 360 CDIS, working directly with physicians as well as other care team members. This team is supported by two educators, allowing for the support you need to be successful in your day-to-day role.

 

This advanced CDI team is progressive and on the forefront of industry CDI strategies in alignment with national organizations such as ACDIS and AHIMA. 


Duties/Responsibilities

  • Leads and coordinates the day-to-day activities of the Clinical Documentation Integrity (CDI) operations at the care sites. Oversee individual CDS workload/assignments and performance. Serves as a subject matter expert and resource for internal customers and Clinical Documentation Integrity Specialists (CDSs). Performs the work of staff.
  • Assists in implementing new SCL Health 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 meetings and CDS peer review activities. Participates in performance improvement/action plan activities
  • Reviews, escalates and assists in escalating unanswered queries to Physician Champion/CMO. Acts as a CDI liaison for other Care Site disciplines to facilitate coordination and collaboration as needed to achieve goals. Assists with quality assurance activities. Audits work of CDSs for accuracy, productivity and quality standards. Proactively identifies issues or trends, and proposes solutions.
  • Communicates issues or concerns with site CDI to CDI Manager.
  • Arranges and delivers education for providers and care givers based on identified opportunities.
  • Works closely with Care Site Chief Medical Officer and CDI Medical Directors to ensure effectiveness of CDI program.
  • Promotes mission, vision, and values of SCL Health, and abides by service behavior standards.
  • Performs other duties as assigned.
Required:
  • Bachelor’s Degree in Nursing required.
  • Active RN license in good standing required. Current Certified Documentation Improvement (CDIP) or Certified Clinical Documentation Specialist (CCDS) within 1 year of hire/eligibility required.
  • One (1) year experience as a Clinical Documentation Specialist (or similar role) in an acute care setting within the last 2 years required.
Organization: Good Samaritan Medical Center, Lafayette, CO
Primary Location: CO-Denver/Boulder/Surrounding Areas-Lafayette
Department: SYS-Clinical Doc Improvement
Schedule: Full-time
Shift: Day Shift
FTE: 1.0
Job Number: 18001766
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