RN Clinical Documentation Specialist Lead- Quality Reviewer - Remote

Ochsner Health • Ligonier, PA

6d • Remote

About The Position

This job functions as the liaison between the customers of the CDI Department and CDI Leadership. The role acts as a clinical and technical resource for CDS staff, answering questions and offering guidance on non-administrative issues. Under leadership direction, it observes, reports, prioritizes, and routes 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 position also performs other duties in support of the department.

The role performs medical record reviews at admission and throughout a patient's stay to assess documentation completeness and accuracy in accordance with Clinical Documentation Program requirements. It communicates with internal and external customers, consults with and educates departmental staff, participates in physician and hospital performance improvement initiatives, and assists the department manager with assigned initiatives. Other related duties may be required.

The position requires completion of a formal nursing training program, at least three years of clinical experience in an acute care setting including Clinical Documentation Improvement experience, advanced clinical expertise, and extensive knowledge of complex disease processes and inpatient care. A current Louisiana Registered Nurse license is required. A bachelor's degree in nursing and CCDS or CDIP certification are preferred. The position is identified as remote, subject to the stated residency restrictions. Physical demands include frequently exerting 10 to 20 pounds of force and occasionally exerting up to 100 pounds; demands exceed those of sedentary work. Reasonable accommodations may be made for individuals with disabilities.

Requirements

• Completion of a formal training program in Nursing.
• At least 3 years of clinical experience in an acute care setting, including Clinical Documentation Improvement experience.
• Advanced clinical expertise and extensive knowledge of complex disease processes, with broad inpatient clinical experience.
• Current State of Louisiana Registered Nurse License.
• Computer skills and dexterity for data entry and retrieval of patient information; proficiency with Windows-style applications and keyboard.
• Effective verbal and written communication skills and ability to present information clearly and professionally to varying audiences.
• Broad-based clinical knowledge and understanding of 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 liaison between CDI Department customers and CDI Leadership.
• Act as a clinical and technical resource to CDS staff, answering questions and providing guidance on non-administrative issues.
• Observe, report, prioritize, and route daily departmental workflow according to Operational Standards and 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 at admission and throughout the patient's 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.
• Support and participate in physician and hospital performance improvement initiatives.
• Assist the department manager with assigned initiatives to enhance departmental efforts.
• Perform other related duties as required.

What This Job Offers

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