Tech Observer · 2 hours ago
Lead Clinical Documentation Improvement (CDI) RN
United States
Contract
Remote
Senior Level
$50/hr - $60/hr
5+ years expTech Observer is focused on improving clinical documentation quality and completeness. They are seeking a Lead Clinical Documentation Improvement RN to enhance documentation accuracy through collaboration with healthcare professionals and ensure compliance for appropriate reimbursement.
BiotechnologyLife SciencePharmaceutical
Hiring Manager
Shubham Singh
Responsibilities
Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes
Assists the Case Management Manager in the day to day responsibilities of overseeing the Documentation Specialists
Includes, but is not limited to, participation in the Documentation Specialist performance appraisal process, supervision of workload assignments, and practice supervision
Plans and implements compliant documentation goals and objectives across the Community Hospital Division (CHD), which support hospital goals and objectives
Assists in development of agendas and in material preparations for meetings to support hospital improvements in identified hospital initiatives, including CDE System Steering Committee
Coordinates and manages program reporting and outcome measurements
Assists the Case Management Manager in the development and updating of policies, procedures and workflow
Facilitates modifications to clinical documentation to ensure compliant documentation with appropriate reimbursement received for the level of service rendered to all patients with a DRG based payor
Improves the overall quality and completeness of clinical documentation, ensuring documentation integrity, by performing initial reviews, continued stays reviews and reconciliation process using the 3M 360 Program
Coordinates professional growth for the Community Hospital Division - RN Clinical Documentation Specialists through appropriate educational opportunities
Coordinates staff development activities related to education, quality assurance and outcome measurements
Facilitates communication and confers with providers face to face or via Clinical Documentation Excellence (CDE) Shared Note to clarify diagnoses information, obtain needed documentation, present opportunities and educate for appropriate DRG based on severity of illness (SOI) and risk of mortality (ROM)
Reviews patient record to ensure points of clarification have been recorded
Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies
Assists with staff recruitment and interviewing RN Clinical Documentation Specialists (CDS) candidates
Serves as Primary lead for orientation and training for new RN CDS
Assists with management of 3M 360 program and serves as subject matter expert with IT on resolution when operations impacted
Other duties as assigned
Qualification
Required
A minimum of five (5) years in an acute care setting as an RN
Working knowledge of computers
Associate degree in Nursing
Requires current state of Wisconsin Registered Nurse License or a Multi-state Nursing License from a participating state in the NLC (Nurse Licensure Compact)
Advanced certification related to CDI (CCDS, CDIP) is required within 6 months of hire
Preferred
Coding experience, i.e. CCS, RHIT background
Bachelor's degree in Nursing
Company
Tech Observer
Tech Observer is a pharmaceuticals company that offers clinical research and analytical support services.
201-500 employees
Funding
Current Stage
Growth StageLeadership Team
♚ Amit Krishnatry
CEO
Company data provided by crunchbase