Clinical Documentation Specialist

    Published
    August 12, 2022
    Location
    8300 Constitution Avenue Northeast, Albuquerque, New Mexico
    Job Type
    State
    New Mexico
    Region
    Southwest

    Description

    We are seeking candidates for a Clinical Documentation Specialist /Educator opportunity (Remote or On Site) for Number one healthcare  in Albuquerque NM.

    Must have at least 3 years of full time Clinical Documentation experience

    Hourly rate $33-$53 an hour

    Sign on bonus:

    Amount Experience Commitment

    $7,500 Less than 1 year 1 year

    $10,000 1 - 4 years 2 years

    $15,000 5+ years 2 years

    $20,000 (OR only) 10+ years 3 years

    M-F No nights or weekends

    Summary

    Serves as educator, consultant, researcher, instructional and evaluation designer, clinical practice expert, and interprofessional collaborator supporting the development needs of staff in the CDI department as well as throughout the PHS enterprise.

    Supports the educational components related to CDI throughout the organization.

    Program Development, Promotion and Oversight Functions: Responsible for planning, implementing, coordinating and delivering education to CDI staff, Presbyterian providers and Presbyterian staff Promotes quality of care and development and maintenance of standard work and clinical guidelines through chart review, process and outcome evaluation and data analysis.

    Responsibilities

    Education, Orientation and Assuring Staff Competence

    Provides educational activities based on learning needs assessments, utilizing the right instructional design, training delivery, and evaluation methodology to provide learning opportunities with high impact

    Builds the approach, deployment, collection, analysis and reports educational program effectiveness to management Drives the implementation of educational content/program in collaboration with management and team members Partners with management to assess clinical performance gaps and build development action plans

    Assists in development of policy and procedures in compliance with AHIMA/ACDIS standards for CDI

    Delivers regular provider Education presentations to include all service lines for employed and contracted providers throughout Central and Regional Delivery Systems (CDS, RDS) as well as new provider orientations

    Participates in continuous education for CDI and Coding and shares knowledge with others

    Conducts regular chart audits to provide education for staff and providers and participates in second level reviews Coordinate educational activities, incorporating ACDIS webinars, designed to increase morale and cohesiveness Incorporates EMR systems into daily work with team and clinical staff Serves as a daily resource to staff

    Reviews Program data to identify opportunities to improve program efficacy through education

    Experience: Minimum 3-5 years experience in CDI. Minimum 5 years of direct nursing prefer ED or critical care. Must demonstrate proficiency in developing and delivering presentations and educational material to clinicians as well as physicians and senior leaders.

    Licensure/Credentials: Essential: RN in State of New Mexico or Compact State License Academic Preparation: Essential: Bachelors degree

    Specialty Certifications: CDIP or CCDS required or must be obtained within one year of hire.

    Detailed Responsibilities Competencies

    Sign on bonus:

    Summary for Lead Documentation Specialist:

    Our client Clinical Documentation Program strives to partner with physicians, Coding and Quality to ensure patient documentation is accurate, specific, comprehensive and reflects the true acuity of care delivered.

    The Lead Clinical Documentation Improvement Specialist oversees quality and process program metrics.

    The goal of the Lead role is to ensure technical documentation and workflow knowledge of clinical documentation specialists and inpatient providers.

    The Lead serves as the primary point for CDI data requests and provides back up support to the Director, CDI.

    The CDI Lead uses clinical, coding, analytical, and project management expertise to ensure the CDI program meets AHIMA/ACDIS/CMS guidelines.

    The Lead uses analytical skills to construct and run quality studies and reports. The Lead also facilitates community-building with CDI Program team members and partners.

    The Lead CDS collaborates with CDI program leadership to develop and implement growth and improvement initiatives with focus on education and building adoption among clinical documentation specialist, coding, inpatient providers, and quality partners.

    Responsibilities for Lead Documentation Specialist (RN):

    The CDI Lead will provide direct support to the Director of CDI and review progress of the concurrent documentation review program, through regular interpretation of process and operational reports, financial and compliance reports, and quality ratings

    reports. Processes and metrics to monitor encompass case assignments, case review prioritization, query escalation, DRG mismatches, CDS/Coder collaboration, provider response rates, CMI, MCC and CC capture rates, HACs/PSIs, and financial

    performance. Identifies areas of focus and necessary process refinements.

    Leads the CDI team in enacting process changes and measuring impact of results. Serves as a resource to CDI staff, physicians, coding, quality and CDI program stakeholders/leaders on issues related to appropriateness of inpatient DRG assignment.

    Evaluates and seeks to improve technology tools, (Epic, 3M 360), communicating new functionality needed and participating in review of upgrade functionality. Manages CDS query templates, ensuring current, easy to use, clear, compliant, and succinct.

    Provides ongoing guidance to CDI staff for compliant queries. Coordinates monthly query reviews with physician advisor and provides feedback to staff.

    Works with CDI program leaders to develop and manage new hire training and orientation program for CDI staff and providers.

    Performs chart audits to assist with identifying needs. Assists with program expansion to other facilities.

    Coordinates with Professional Development Specialist to create and present targeted physician education and communicates

    feedback to CDI program leaders.

    Assists CDI Director with scheduling of staff and case assignments to assure appropriate coverage. Assists CDI Director with payroll. Assists in evaluation of staff. Provides direct support to CDI department when Director is unavailable. Leads DMS huddles in coordination with Director.

    Raises operational needs and improvement opportunities to CDI program leaders. This includes feedback to physician advisor on

    provider education needs. Participates in monthly quality program meetings. Leads monthly CDI/CDQA/Coding collaborative round

    table meetings.

    Monitors second level review program, tracking log, and training for program.

    Perform other functions as required.

     

    Qualification for the Lead Documentation Specialist (RN):

    Education: Associates Degree required.

    RN with 3-5 years of CDI experience and 5 years of direct nursing experience with preference to ED or critical care.

    BSN or RN with Bachelors Degree required, or must obtain within five years from hire date. Excellent written and verbal communication skills.

    Developed Critical thinking and analytical ability required. Experience with database, spreadsheet and word process required.

    Detail and results oriented with the ability to maintain accurate, detailed and organized records is essential.

     

    Ability to work independently and make independent decisions. Working knowledge of medical terminology, ICD-10, CPT, HCPSC and DRG required.

    Must possess knowledge of disease processes and related procedures. Up to date clinical skills and current working knowledge of pathology and pharmacology impacts on care required.

    Experience in working directly with physicians, including knowledge of conflict resolution techniques preferred. Ability to identify physician perceptions and/or concerns and act on this information in a tactful manner. Able to maintain composure when dealing with physicians and hospital staff.

    Must possess excellent clinical skills, advanced problem solving ability and is able to role model and teach others in a non-threatening supportive manner. Maintain positive interdepartmental relations and develop effective collegial collaboration.

    Licensed as Registered Nurse in State of New Mexico. CCDS or CDIP required or must obtain within one year of hire.

    Ability to work independently and make independent decisions. Working knowledge of medical terminology, ICD-10, CPT, HCPSC and DRG required.

    Must possess knowledge of disease processes and related procedures. Up to date clinical skills and current working knowledge of pathology and pharmacology impacts on care required.

    Experience in working directly with physicians, including knowledge of conflict resolution techniques preferred. Ability to identify physician perceptions and/or concerns and act on this information in a tactful manner. Able to maintain composure when dealing with physicians and hospital staff.

     

    Must possess excellent clinical skills, advanced problem solving ability and is able to role model and teach others in a non-threatening supportive manner. Maintain positive interdepartmental relations and develop effective collegial collaboration.

    Licensed as Registered Nurse in State of New Mexico. CCDS or CDIP required or must obtain within one year of hire.

    Benefits:

    401(k)

    401(k) matching

    Dental insurance

    Disability insurance

    Employee assistance program

    Employee discount

    Flexible schedule

    Flexible spending account

    Health insurance

    Life insurance

    Paid time off

    Referral program Clinical Documentation Specialist /Educator (Remote or On Site)

    Relocation assistance

    Travel reimbursement

    Tuition reimbursement

    Vision insurance

     

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