RN Clinical Documentation Specialist Lead- Remote- Days
RemoteCalifornia, United States or Washington, District of Columbia, United States
Job Summary
Conduct medical record reviews for patient admissions and throughout stays to ensure documentation completeness and accuracy per Clinical Documentation Program requirements. Serve as the liaison between CDI customers and leadership, acting as a clinical resource to answer questions and guide non-administrative issues. Observe, report, and re-route daily department workflows according to operational standards while maintaining responsibility for running operational reports and forwarding key metrics to leadership at scheduled intervals. Facilitate special record reviews, projects, and customer requests, and actively support physician and hospital performance improvement initiatives. Provide consultation and education to departmental staff and assist the manager in assigned departmental initiatives to enhance overall efforts.
Required Qualifications
- Completion of a formal training program in Nursing
- Bachelor's degree in Nursing
- 3 years clinical experience in an acute care setting including experience in Clinical Documentation Improvement
- Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting
- Current State of Louisiana Registered Nurse License
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP)
- Computer skills and dexterity required for data entry and retrieval of patient information
- Proficiency with Windows-style applications and keyboard
- Effective verbal and written communication skills and the ability to present information clearly and professionally to varying levels of individuals
- Broad-based clinical knowledge and understanding of pathology/physiology of disease processes
- Strong organizational skills
- Self directed
- Frequently exerting 10 to 20 pounds of force to move objects
- Occasionally exerting up to 100 pounds of force
Desired Qualifications
- Remote work location (excluding Colorado, California, Hawaii, Illinois, Maine, Maryland, Massachusetts, Minnesota, New Jersey, New York, Vermont, Washington, Washington D.C.)
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