Clinical Documentation Education Lead

🕒 September 2

🇺🇸 United States – Remote

⏰ Full Time

🟠 Senior

🏥📝 Medical Writer

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Wellstar Health System

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1992

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Wellstar Health System is a comprehensive healthcare organization dedicated to providing personalized and compassionate care to patients in Georgia and South Carolina. With a diverse range of career opportunities, Wellstar supports its employees' career growth and wellbeing through a positive culture, excellent benefits, and a focus on diversity, equity, and inclusion. The organization emphasizes the importance of treating both patients and staff with respect and care, making it a sought-after workplace in the healthcare industry. Wellstar is committed to offering high-quality healthcare services and maintaining strong community engagement.

📋 Description

• Collaborate with CDI leadership, coding teams, providers, auditors, and operational leadership to improve documentation and coding accuracy • Assess provider and CDI team knowledge and skill gaps using data trends, CDI KPIs, audit results, industry events, and leadership needs • Develop, tailor, and deliver live and recorded CDI education and training • Train providers on documentation best practices and clinical documentation specialists on operations, skills, teamwork, customer service, and change management • Conduct new employee orientations, skills development, and new-user technology training • Create education materials, training materials, presentations, and meeting resources • Provide timely follow-up education based on CDI and Coding audit results and query activity • Assist with testing future CDI technology enhancements and function as a super user for CDI software and applications • Review clinical documentation remotely during patient admissions • Perform hospital-wide medical record reviews to improve completeness, accuracy, coding compliance, reporting, and patient outcomes • Submit compliant electronic queries to clinicians and provide appropriate follow-up • Escalate unanswered queries according to the Wellstar Query Escalation process • Reconcile records daily in the Solventum/3M 360 Encompass CDI tool • Review Coding Clinic changes and maintain current knowledge of coding, billing, medical terminology, procedures, medications, and diseases • Participate in required meetings, conference calls, and stakeholder presentations • Support regulatory compliance and departmental policies • Perform other duties as assigned

🎯 Requirements

• Associate's degree in Nursing, bachelor's degree in Health Science, accredited Health Science program, or Doctorate of Medicine • Certified Clinical Documentation Specialist within 180 days of hire or Certified Documentation Improvement Practitioner within 180 days of hire • Minimum 2 years working in an acute care setting as a Clinical Documentation Specialist (CDS) • Minimum 5 years of healthcare experience • Strong understanding of disease processes, clinical indications, treatments, and provider documentation requirements • Knowledge of Medicare, Medicaid, and commercial payer coding and billing rules • Familiarity with an encoder and current working knowledge of Coding Clinic Guidelines and federal updates to MS and APR DRG systems • Expert knowledge/experience in Clinical Documentation Integrity, including productivity, quality, education and training, compliance auditing, data analysis and trending, report management, and performance improvement initiatives • CDI/Coding chart review experience • Excellent communication, presentation, problem-solving, time management, training, and peer development skills • Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives • Proficient computer skills in Microsoft Word, Excel, PowerPoint, and CDI technology tools • Comfortable performing data analysis and preparing and maintaining records and written reports • Ability to leverage technology and reporting capabilities to identify education opportunities • RNs must be licensed, knowledgeable, and uphold nursing practice standards upon hire • Non-clinical/coding candidates must have at least one active/current CCS, CPC, RHIA, or RHIT certification upon hire

🏖️ Benefits

• Virtual/remote work arrangement • Supportive work environment • Meaningful work in healthcare • More rewarding life and employee support