Clinical Documentation Education Lead

This is a fully remote position, open to applicants in United States.

📋 Description

• Collaborate with leadership in Clinical Documentation Improvement (CDI), coding teams, healthcare providers, auditors, and operational leaders to enhance the accuracy of documentation and coding.

• Evaluate the knowledge and skill gaps of providers and the CDI team by analyzing data trends, CDI key performance indicators (KPIs), audit outcomes, industry events, and leadership requirements.

• Design, customize, and deliver both live and recorded educational sessions and training for CDI.

• Educate providers on best practices for documentation and train clinical documentation specialists on operations, skills, teamwork, customer service, and change management.

• Conduct orientations for new employees, facilitate skills development, and provide training for new users on technology.

• Develop educational materials, training resources, presentations, and materials for meetings.

• Offer prompt follow-up education based on the results of CDI and coding audits and query activities.

• Assist in testing future enhancements in CDI technology and act as a super user for CDI software and applications.

• Review clinical documentation remotely during patient admissions.

• Conduct comprehensive medical record reviews across the hospital to enhance completeness, accuracy, coding compliance, reporting, and patient outcomes.

• Submit compliant electronic queries to clinicians and ensure appropriate follow-up is provided.

• Escalate any unresolved queries following the Wellstar Query Escalation process.

• Reconcile records on a daily basis using the Solventum/3M 360 Encompass CDI tool.

• Stay updated on Coding Clinic changes and maintain a current understanding of coding, billing, medical terminology, procedures, medications, and diseases.

• Participate in mandatory meetings, conference calls, and presentations to stakeholders.

• Support compliance with regulations and departmental policies.

• Perform additional duties as assigned.

⛳️ Requirements

• Associate's degree in Nursing, bachelor's degree in Health Science, completion of an accredited Health Science program, or Doctorate of Medicine.

• Acquire certification as a Clinical Documentation Specialist within 180 days of employment or as a Certified Documentation Improvement Practitioner within 180 days of hire.

• A minimum of 2 years of experience working in an acute care setting as a Clinical Documentation Specialist (CDS).

• At least 5 years of experience in the healthcare field.

• In-depth understanding of disease processes, clinical indications, treatments, and the documentation requirements of providers.

• Familiarity with Medicare, Medicaid, and commercial payer coding and billing regulations.

• Knowledge of an encoder and current understanding of Coding Clinic Guidelines and federal updates affecting MS and APR DRG systems.

• Extensive knowledge and experience in Clinical Documentation Integrity, including productivity, quality, education and training, compliance auditing, data analysis and trending, report management, and performance improvement initiatives.

• Experience in CDI/Coding chart review.

• Strong communication, presentation, problem-solving, time management, training, and peer development skills.

• Ability to interpret, adapt, and implement guidelines, procedures, and ongoing quality improvement initiatives.

• Proficient in Microsoft Word, Excel, PowerPoint, and CDI technology tools.

• Comfortable conducting data analysis and preparing and maintaining documentation and written reports.

• Capability to utilize technology and reporting tools to identify educational opportunities.

• Registered Nurses (RNs) must be licensed, knowledgeable, and adhere to nursing practice standards upon hire.

• Candidates for non-clinical/coding roles must possess at least one active/current CCS, CPC, RHIA, or RHIT certification at the time of hire.

🏝️ Benefits

• Virtual/remote work options available.

• Supportive and collaborative work environment.

• Engaging and meaningful work within the healthcare sector.

• Enhanced life quality and employee support initiatives.