RN Clinical Documentation Specialist Lead- Quality Reviewer

Ochsner Clinic Foundation • New Orleans, LA

4d

About The Position

This role functions as the liaison between customers of the Clinical Documentation Improvement (CDI) Department and CDI Leadership. The lead serves as a clinical and technical resource for CDI staff, answering questions and providing guidance on non-administrative issues. Under leadership direction, the position observes, reports, prioritizes, and redirects daily departmental workflow according to operational standards; runs operational reports and forwards key metrics to leadership at regularly scheduled intervals; and facilitates special record reviews, projects, and other customer requests. The role also performs medical record reviews for documentation completeness and accuracy, provides staff consultation and education, supports performance improvement initiatives, and assists the department manager with assigned initiatives. Other duties may be required.

Requirements

• Completion of a formal training program in Nursing.
• At least 3 years of clinical experience in an acute care setting, including experience in Clinical Documentation Improvement.
• Advanced clinical expertise and extensive knowledge of complex disease processes, with broad clinical experience in an inpatient setting.
• Current State of Louisiana Registered Nurse License.
• Computer skills and dexterity required for data entry and retrieval of patient information.
• Proficiency with Windows-style applications and keyboard use.
• Effective verbal and written communication skills, including the ability to present information clearly and professionally to people at varying levels.
• Broad-based clinical knowledge and understanding of the pathology and physiology of disease processes.
• Strong organizational skills.
• Self-directed.

Nice To Haves

• Bachelor's degree in Nursing.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP).

Responsibilities

• Serve as a liaison between CDI Department customers and CDI Leadership.
• Act as a clinical and technical resource to CDI staff, answering questions and providing guidance on non-administrative issues.
• Observe, report, prioritize, and reroute daily departmental workflow according to operational standards under leadership direction.
• Run operational reports and forward key metrics to leadership at regularly scheduled intervals.
• Facilitate special record reviews, projects, and other customer requests.
• Review medical records on patient admission and throughout the stay for documentation completeness and accuracy in accordance with Clinical Documentation Program requirements.
• Communicate effectively and appropriately with internal and external customers.
• Provide consultation and education to departmental staff.
• Actively support and participate in physician and hospital performance improvement initiatives.
• Assist the department manager with assigned departmental initiatives.
• Perform other related duties as required.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed