Clinical Documentation Specialist Lead RN

Job Summary

Job Duties

• Provides concurrent review of the clinical documentation in the medical record.
• Formulates queries via written and verbal communication when it is determined there is missing documentation, conflicting documentation or unclear documentation.
• Performs a thorough chart review to identify and capture any secondary diagnosis, or complications within the concurrent tracking software for quality ratings and profiling purposes.
• Serves as an operations coordinator for the team, in addition to performing the above regular duties within the job description.
• Lead responsibilities would include: Assists with the scheduling of staff for appropriate coverage.
• Assists with query reconciliation and DRG mismatches with clinical documentation and coding Provides feedback to Director on operational concerns.
• Provides feedback to Physician Advisor on provider query performance.
• Provides ongoing feedback to leadership.
• Serves as a subject matter expert and authoritative resource on interpretation and application ofclinical documentation.
• Participates in the training of all new CDI staff, including on-going mentorship.

Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.

Position Details

Education

Experience

Certification(s) and License(s)