Clinical Document Specialist III

About the role

We are seeking an enthusiastic and experienced Clinical Document Specialist III to join our dynamic healthcare team. This role is critical in leading the Clinical Documentation Improvement (CDI) team to ensure the accuracy, integrity, and quality of patient records. The successful candidate will have a strong understanding of various medical departments, including emergency, surgical, intensive care, and post-acute care units. The role demands a professional with a proven track record in healthcare quality management, specifically in the areas of CMS and CCDS.

Responsibilities

• Lead the Clinical Documentation Improvement (CDI) team to ensure high-quality documentation of clinical care.
• Develop and implement strategies to enhance the accuracy, completeness, and consistency of clinical documentation.
• Provide guidance and training to the CDI team on clinical documentation standards and best practices.
• Collaborate with medical, surgical, intensive care, and post-acute care units to ensure alignment of documentation practices.
• Conduct regular audits of clinical documentation and provide feedback to the CDI team and healthcare providers.
• Monitor and report on CDI quality metrics, identifying areas for improvement and implementing corrective actions.
• Stay updated on CMS and CCDS guidelines and ensure compliance within the organization.
• Foster a culture of continuous improvement, encouraging innovation and efficiency within the CDI team.

Qualifications

• A bachelor's or higher educational degree. An advanced degree will be an added advantage.
• A minimum of 5 years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
• A minimum of 2 years of experience of Clinical Documentation Specialist experience.
• RN, NP, or PA licensure.
• Demonstrated experience in leading a CDI team in a healthcare setting.
• Extensive knowledge of CMS and CCDS guidelines.
• Strong leadership and team management skills, with the ability to motivate and guide a team towards achieving high-quality outcomes.
• Excellent communication and interpersonal skills, with the ability to collaborate effectively with healthcare providers and administrators.
• Proficiency in using healthcare information systems and software.
• Certification in Clinical Documentation Improvement (CCDI) or equivalent is desirable.

Benefits

• Excellent Medical, Dental, Vision
• Growth Opportunity
• Established Healthcare Organization
• Hybrid work environment
• Relocation Assistance