LEAD CDI- CLINICAL DOCUMENTATION IMPROVEMENT - Baptist Health Care

The Clinical Documentation Improvement Team Lead provides a key role in facilitating long-term success of clinical documentation improvement by providing day-to-day intense oversight of the clinical documentation improvement program at the facility level. The Clinical Documentation Improvement Team Lead will work under the direction of the Clinical Documentation Improvement Manager and in collaboration with the clinical documentation specialists (CDS), coding professionals, physicians, physician champions, physician’s assistants’ and certified registered nurse practitioners to ensure accurate and timely clinical documentation in the medical record that supports the coding process in attaining appropriate DRGs based on sound clinical entries in the medical record.  

The Clinical Documentation Improvement Team Lead is responsible for managing the day-to-day operations of the Clinical Documentation Improvement program and ensuring program productivity benchmarks are achieved and maintained. The Team Leader will function as a subject matter expert for Clinical Documentation Improvement and support ongoing communication and education on documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies to the Clinical Documentation Improvement team and hospital staff.  The Clinical Documentation Improvement Team Lead will function as the Clinical Documentation Improvement Task Force Committee chair and participate in Clinical Documentation Improvement Steering Committee (Administration) meetings to provide all around oversight of the day-to-day operations of the Clinical Documentation Improvement program.

The person in this position works under general supervision, is responsible for various shifts, may be subject to over 40 hours per week and/or callback as required, and may also be required to remain on campus immediately before, during, and after severe weather and/or disasters.

• Associates of Nursing degree is required
• Five years of adult acute care experience in Med/Surg, Critical Care, Emergency Room, or PACU is required
• Current state Registered Nurse License in the state of Florida
• Organizational, analytical, writing and interpersonal skills. Excellent knowledge of Word/Excel/Power Point. Knowledge of ICD-10, DRG and other hospital reimbursement methodology (Training provided). Knowledge of regulatory environment.
• Understand and support Clinical Documentation Improvement documentation strategies
• Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments