Lead Clinical Documentation Coordinator

UHS • Aiken, SC

9h

About The Position

The Lead Clinical Documentation Coordinator manages the Clinical Documentation Improvement (CDI) program and its staff. The role identifies opportunities for improvement by interpreting process and operational reports, financial and compliance reports, and quality ratings. It oversees review scheduling and coverage, query development and auditing, physician education, program monitoring, and process refinement to clarify documentation in medical records.

The coordinator follows up on unanswered queries during patient stays as needed and serves as a resource to physicians and administration on appropriate inpatient DRG assignment. In collaboration with the CDI team and other healthcare professionals, the role supports documentation that reflects patients’ severity of illness and risk of mortality using appropriate query tools and strong communication skills.

The position provides day-to-day staff supervision, employee relations, and staff development; serves as the CDI program and application-software super-user and trainer; and educates internal customers on compliant documentation requirements related to DRG revenue assurance, compliance, and quality outcomes. It also oversees CDIS audits to ensure queries are compliant and effective and provides guidance and leadership to the CDI team. Other duties may be assigned or required.

Requirements

• Graduate of a nursing program.
• Minimum of 5 years of recent clinical experience in an acute care setting.
• Three to five years of experience with inpatient coding and DRG guidelines.
• Ability to work independently in a time-oriented environment.
• Excellent written and verbal communication skills.
• Knowledge of age-specific needs and elements of disease processes and related procedures.
• Strong broad-based clinical knowledge and understanding of the pathology and physiology of disease processes.
• Computer literacy.
• Registered Nurse with a current South Carolina license.

Nice To Haves

• Bachelor of Science in Nursing (BSN).
• Critical Care or Medical/Surgical experience.
• Working knowledge of the Medicare reimbursement system and coding guidelines.
• RHIA, RHIT, or CCS credential.

Responsibilities

• Manage the operations of the Clinical Documentation Improvement (CDI) program.
• Manage departmental staff, including day-to-day supervision, employee relations, and staff development.
• Identify improvement opportunities by analyzing process and operational reports, financial and compliance reports, and quality ratings.
• Coordinate appropriate scheduling and coverage of reviews.
• Oversee query development, auditing, and follow-up on unanswered queries during patient stays as needed.
• Educate physicians and monitor the CDI program, refining processes as needed to clarify medical-record documentation.
• Serve as a resource to physicians and administration regarding the appropriateness of inpatient DRG assignment.
• Collaborate with CDI team members and healthcare professionals to support documentation that reflects patients’ severity of illness and risk of mortality.
• Serve as the super-user and trainer for the CDI program and application software used to code or assign working MS-DRG, APR-DRG, SOI, and ROM.
• Provide internal customers with education on CDI program effectiveness and compliant documentation requirements related to DRG revenue assurance, compliance, and quality outcomes.
• Oversee CDIS audits to ensure queries are compliant and effective.
• Provide influence, guidance, and management to the CDI team.
• Perform other duties as assigned or required.

Benefits

• Unlimited employee referral bonus program.
• Competitive compensation and generous paid time off.
• Medical, dental, vision, and prescription drug plans.
• Tuition and certification reimbursement after six months.
• Employee recognition program.
• Clinical Nursing Ladder opportunities.
• SoFi student loan refinancing program.
• 401(k) with company match and discounted stock plan.
• Career development opportunities within UHS and its subsidiaries.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior