Registered Nurse, Clinical Documentation – CDI Educator/Auditor, CCDS Required

Job Description:

• Participate in daily Clinical Documentation Department activities
• Facilitate documentation improvements to accurately depict clinical services and patient severity
• Perform department audits and second-level reviews
• Provide orientation, training, and education for CDI staff
• Support focused provider education and ongoing physician education
• Maintain knowledge of program metrics and support timely, accurate data reporting
• Use 3M-360 applications to identify learning needs of CDI nurses, residents, physicians, and administrative staff
• Provide day-to-day educational support for clinical documentation priorities
• Function as a Clinical Documentation Specialist when not engaged in educational activities
• Review CDS productivity reports and meet quarterly with each CDS team member
• Manage reconciliation processes and conduct internal audits for feedback, data accuracy, and performance improvement
• Manage process flow and communication and education plans, including onboarding and continuing education
• Coordinate with Clinical Documentation Specialists, CDI Associate, administrative support, and the manager
• Partner with HIM and Clinical Documentation leadership on education, training, and coding guidelines
• Monitor documentation against core-measure quality indicators and address opportunities with physicians and advanced health practitioners
• Collaborate with patient safety and coding teams to maintain accuracy of codes associated with patient safety indicators

Requirements:

• Current Registered Nurse license in the State of Georgia
• Clinical Documentation Specialist (CCDS) certification required
• Bachelor's degree
• 5–10 years of clinical nursing experience
• 3–5 years of clinical documentation experience
• Comprehensive knowledge of acute med-surg, critical care, and cardiology nursing
• Excellent verbal and written communication, interpersonal, collaboration, critical thinking, prioritization, and organization skills
• Excellent computer skills, including Microsoft Office applications
• Experience with databases, spreadsheets, and presentation software
• Ability to develop and implement strategic direction and vision for project management and work priorities
• Advanced analytical skills in health information workflow analysis and planning
• Knowledge of hospital organization/administration and applicable health information management and CDI laws
• Knowledge of Medicare Part A and Part B guidelines
• Ability to communicate clearly with stakeholders orally and in writing
• Ability to work independently in a collaborative, shared-leadership environment

Benefits:

• Full-time employment
• Equal opportunity employment