Job description
Overview
How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.
Responsibilities
The Clinical Documentation Specialist (CDS) Team Leader demonstrates excellent Leadership Skills, problem-solving, clinical knowledge, and coding knowledge requirements to support and improve the overall quality and completeness of clinical documentation in the patient medical record on a concurrent basis supporting and using a multi-disciplinary team process. The CDS Team Leaders works collaboratively with the CDS Staff, physicians and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate clinical severity is captured for the level of service rendered to all patients. The CDS Team Leader also supports the Departmental goal and philosophy of positive Team Building, mentoring, coaching and constructive feed-back as well as achieving clinical and operational excellence in relation to Clinical Documentation Improvement efforts.
Qualifications
Required Minimum Education
- Bachelor’s degree in nursing or other health-related field desirable
Required Minimum Licensure/Certification
At least one of the following current/active certification/licensure required:
- RN: Current/active license as a Registered Nurse in the state of residence or current/active RN license with ability to transfer license to state of residence within three months of start
- CCDS: Certified Clinical Documentation Specialist
- CDIP: Clinical Documentation Improvement Practitioner
- CCS: Certified Coding Specialist, or equitable coding credential
- RHIA/RHIT : Registered Health Information Administrator/Technician
Required Minimum Experience
- Minimum of two years as a Clinical Documentation Specialist is required
- Minimum of seven years of healthcare experience preferred, strong medical surgical and/or critical care background is preferred
- Minimum of five years as a Clinical Documentation Specialist is preferred
- Experience with utilization management, coding, billing, auditing and various healthcare payers is also preferred
- Clinician preferred and/or CDIP/CCDS credential
- It is expected that all RN’s are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association
Required Minimum Skills
- Medical Chart review experience required
- High level of written communication skills necessary to establish rapport with physicians, other Team members, coding team and all other customers as applicable
- Excellent time management, training and peer development skills
- High level of motivational and interpersonal skills
- Strong written and verbal communication skills, decision-making and analytical skills, advanced computer skills and ability to work well under pressure individually and as part of a team
- Minimum MS Office (Word, Outlook, Excel and PowerPoint) knowledge and expertise is expected
- EPIC Electronic Medical Record and CDI Software experience is preferred
- Regulatory background and DRG reimbursement knowledge and strong understanding of coding methodologies and guidelines preferred
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