UF Health

Clinical Documentation Specialist Lead (RN) | Medical Records | Full Time

Posted on

February 10, 2025

Job Type

Full-Time

Role Type

Leadership / Management

License

RN

State License

Florida

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Company Description

Job Description

The Clinical Documentation Specialist Team Lead reviews the progress of the CDI program, through interpretation of reports and quality rating reports. Able to identify areas of focus and necessary process refinements through report analysis. Leads CDI team in enacting process changes and measuring efficacy and impact of results. Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment. This position is fully remote within the State of Florida.

Requirements

Education Requirements: RN or Unlicensed physician who has graduated from a medical school that is listed in the World Directory of Medical Schools (World Directory) as meeting eligibility requirements for its graduates to apply to the Educational Commission for Foreign Medical Graduates (ECFMG) for ECFMG Certification and examination at the time of graduation. Experience Requirements: 5 years nursing experience in an acute care setting to include inpatient bedside nursing and Case Management or CDI experience Licensing/Certifications Required: Current FL RN License or ECFMG Registry Certified Clinical Documentation Specialist (CCDS)

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Responsibilities

Perform concurrent and retrospective second level reviews on specific types of opportunities Strategic approach and process refinements to capture opportunity within the CDS team Track progress of CDI team in capturing opportunities and prioritizing workload effectively Develop and oversee new hire training and orientation program for new CDSs Track query escalation process and DRG mismatches Provide feedback and educational growth opportunities to the CDI team Provide feedback to physician champion(s) on provider engagement/response Create and present targeted physician education Serve as main point of contact for external and internal CDI data requests Track technology issues with process tools and coordinate with IT on updates Perform all other duties as assigned by management within job scope

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