Registered Nurse – Clinical Documentation Specialist Lead

Job Description:

• Performs duties of a clinical documentation specialist and serves as a mentor and resource to the clinical documentation improvement team.
• Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate Diagnosis Review Group (DRG) assignment, risk of mortality (ROM), and severity of illness (SOI).
• Generates and distributes query escalation reports to physician advisors.
• Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
• Educates physicians and key healthcare providers regarding clinical documentation improvement (CDI) and the need for accurate and complete documentation in the health record.
• Trains and mentors new CDI staff on CDI strategy, workflows, and software.
• Maintains a level of expertise by attending continuing education programs.

Requirements:

• Graduate of accredited school of nursing or education equivalency for licensing
• Two years' acute care experience and three years' clinical documentation specialist experience.
• State of Work Location: Illinois Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
• State of Work Location: Missouri Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Missouri Division of Professional Registration
• State of Work Location: Oklahoma Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)
• State of Work Location: Wisconsin Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services.

Benefits:

• Paid Parental Leave: we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).
• Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay (fees may apply) before payday.
• Upfront Tuition Coverage: we provide upfront tuition coverage through FlexPath Funded for eligible team members.

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