RN TEAM LEAD - CLINICAL DOC INTEGRITY - CalvertHealth
Dares Beach, MD 20678
About the Job
- JOB DESCRIPTION DETAILS
- Job Summary:
- Demonstrates excellent problem-solving, clinical knowledge, and coding knowledge. Facilitates the overall quality, completeness, and accuracy of clinical documentation in patient medical records on a concurrent basis. Works collaboratively with providers, case managers, coders, and other health care team members. As part of a multidisciplinary team, ensures that clinical information in the medical record is present and accurate so that the appropriate clinical severity is captured for the level of service rendered. Serves as a resource and provides guidance, support, education, and training on clinical documentation guidelines. Supports departmental and organizational goals to achieve clinical and operational excellence in relation to Clinical Documentation Improvement efforts.
- Education:
Position requires a Bachelor’s Degree in Healthcare or Nursing. Master’s degree in Health Administration or other related master’s degree is preferred but not required.
- Registration/Certification/Licensure:
- Compact state Registered Nurse (RN) required. Certified Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement Specialist (CDIS) preferred.
- Experience:
- Minimum of 5 years’ experience in a acute care hospital clinical setting required, 3 years of Clinical Documentation Improvement experience preferred. Utilization Review and / or Case Management experience preferred but not required.
- Other Requirements:
- Maintains unit-specific and hospital competencies, mandatory learning, and any clinical certifications required in accordance with the Staff Education and Training policy GA-057 and/or any other department requirements.
- Intermediate skill level on the computer: Office Products including Word, Excel, and PowerPoint.
- Demonstrates skills in planning, organizing, and managing multiple functions and complex processes.
- Maintains a fast pace, coordinates and is able to multi-task process of requests, and acknowledgement of data and correspondence.
- Must be able to identify and correct weaknesses in the process and alert leadership in the event of negative results/outcomes.
- Requires understanding of many complex and varying guides, systems, regulations, and tools.
- Utilizes critical thinking skills to manage an ever evolving process that includes financial, clinical and medical/legal components.
PI250610331
Source : CalvertHealth
