Clinical Documentation Improvement Team Lead / RN

Overview

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• Comprehensive health benefits that start day 1
• Student Loan Repayment Assistance & Reimbursement Programs
• Family-focused benefits
• Wellness incentives
• Ongoing mentorship and leadership programs
• And more!

Description

The Clinical Documentation Improvement Team Lead assists with the daily operations of the clinical documentation improvement program within the Health Information Management (Medical Records) department in addition to the regular responsibilities of a Clinical Documentation Improvement Specialist. The Clinical Documentation Improvement Team Lead assists HIM Management as a point person for clinical documentation improvement activities. The Clinical Documentation Improvement Team Lead provides guidance, support and oversight to the CDI Staff to ensure that the clinical documentation improvement team operates efficiently and maintains high standards of quality and compliance.

• Provides patient care, treatment, and services within the scope of their license, certification, registration, and/or assessed competencies.
• Practice will be in accordance with laws and regulations and will adhere to established policies, procedures and practice guidelines.
• Reviews inpatient medical records throughout hospitalization as defined in the Clinical Documentation Improvement Policy and Procedure.
• Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.
• Queries attending physician to validate observations and request additional and/or more specific documentation.
• Monitors day to day operations of the CDI Team; reporting feedback and trends to Management.
• Tracks and analyze query opportunities.
• Monitors CDI Reports on a Weekly basis to ensure accuracy.
• Audits Clinical Documentation Specialists to ensure query compliance.
• Identifies risk factors and educates.
• Monitors outstanding post discharge queries.
• Monitors query responses concurrently. Assists in educating the clinical documentation improvement team. MINIMUM QUALIFICATIONS:
• Must have a valid, active unencumbered Nursing license or temporary permit approved by the Georgia Licensing Board.
• Minimum five (5) years experience adult inpatient med-surg or critical care.
• Case Management experience preferred. CCS, CDIP, or CCPC preferred certification.
• Two years hospital or related clinical documentation program management experience in a multi-hospital system.
• Strong knowledge of Coding Guidelines, Coding Clinics, MS DRG's, and Query Guidelines required.

JOIN OUR TEAM TODAY! Emory Healthcare (EHC), part of Emory University (EUV), is the most comprehensive academic health system in Georgia and the first and only in Georgia with a Magnet® designated ambulatory practice. We are made up of 11 hospitals-4 Magnet® designated, the Emory Clinic, and more than 425 provider locations. The Emory Healthcare Network, established in 2011, is the largest clinically integrated network in Georgia, with more than 3,450 physicians concentrating in 70 different subspecialties.

Additional Details

Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.

Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcare’s Human Resources at [email protected]. Please note that one week's advance notice is preferred.