Lead Clinical Documentation Specialist - CDI - CDS

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SCL Health is currently offering a $2,500 sign-on bonus for new hire Clinical Documentation Specialists!


In collaboration with the Clinical Documentation Specialist Manager, the Lead Clinical Documentation Specialist assists with the daily operations and supervision of the Clinical Documentation Integrity team at St. Mary’s Medical Center. The Lead Clinical Documentation Specialist reviews electronic health records, acts as a second-level reviewer before escalation to Physician Champion/CMO, and assists with implementation of new CDI policies, practices and procedures. The Lead Clinical Documentation Specialist acts as a liaison to the multidisciplinary care team and serves as a subject matter expert and educator for CDI-related information.  Along with the CDI Educator, the Lead Clinical Documentation Specialist facilitates the professional development and continuing education of clinical documentation specialists at St. Mary’s Medical Center.


Primary responsibilities include:

  • Daily onsite management of the Clinical Documentation Specialists
  • Planning and execution of team huddles and other site based meetings.
  • Coaching physicians, nurses and other clinicians on complete, compliant and accurate documentation.
  • Assist CDS Manager in evaluation of care site CDSs
  • Collaboration with other disciplines to identify opportunities for improved workflow
  • Communication with HIM staff to resolve discrepancies.
  • In depth knowledge of CDI core concepts and processes and knowledge of Medicare Parts A and B, Coding Guidelines and quality initiatives.
  • The information above is for summary purposes, and is not intended to be a comprehensive list of essential functions.

Bachelor’s degree in Nursing, required

Valid license in the state of practice, required

CDIP or CCDS certification, required (or ability to obtain within one year of hire)

Two years of experience in clinical documentation integrity/improvement, required

Three years of experience in adult acute care, required

Ability to work collaboratively and independently, required

Organization: Corporate, Various Locations
Primary Location: CO-Grand Junction
Department: SYS-Clinical Doc Improvement
Schedule: Full-time
Shift: Day Shift
Job Posting: 1/16/2017 10:58:00 PM
FTE: 1.0
Job Number: 16003354
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