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

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

📋 Description

• Engage in daily activities of the Clinical Documentation Department

• Enhance documentation to accurately reflect clinical services and patient severity

• Conduct departmental audits and perform second-level reviews

• Offer orientation, training, and education for CDI personnel

• Assist with targeted provider education and ongoing physician training

• Stay informed about program metrics and ensure timely, accurate data reporting

• Utilize 3M-360 applications to assess learning needs of CDI nurses, residents, physicians, and administrative staff

• Provide daily educational assistance focused on clinical documentation priorities

• Act as a Clinical Documentation Specialist when not involved in educational tasks

• Analyze CDS productivity reports and conduct quarterly meetings with each CDS team member

• Oversee reconciliation processes and perform internal audits for feedback, data accuracy, and performance enhancement

• Manage process flow along with communication and educational plans, including onboarding and ongoing education

• Collaborate with Clinical Documentation Specialists, CDI Associates, administrative support, and management

• Work alongside HIM and Clinical Documentation leadership on education, training, and coding standards

• Monitor documentation in relation to core-measure quality indicators and address potential improvements with physicians and advanced health practitioners

• Partner with patient safety and coding teams to ensure the accuracy of codes related to patient safety indicators

⛳️ Requirements

• Valid Registered Nurse license in the State of Georgia

• CCDS (Clinical Documentation Specialist) certification is mandatory

• Bachelor's degree required

• 5–10 years of clinical nursing experience necessary

• 3–5 years of experience in clinical documentation required

• Extensive knowledge of acute medical-surgical, critical care, and cardiology nursing

• Strong verbal and written communication, interpersonal, collaboration, critical thinking, prioritization, and organizational skills

• Proficient computer skills, including Microsoft Office applications

• Familiarity with databases, spreadsheets, and presentation software

• Capability to develop and implement strategic direction and vision for project management and work priorities

• Advanced analytical skills in health information workflow analysis and planning

• Understanding of hospital organization/administration and relevant health information management and CDI regulations

• Knowledge of Medicare Part A and Part B guidelines

• Ability to communicate effectively with stakeholders both orally and in writing

• Competence to work independently within a collaborative, shared-leadership environment

🏝️ Benefits

• Full-time employment

• Equal opportunity employment