Clinical Documentation Specialist Team Leader

Baptist Health is the largest healthcare system serving central Alabama, providing comprehensive hospital-based and outpatient services to nearly 60 percent of the residents in Montgomery, Autauga and Elmore counties.

To learn more about Baptist Health, visit us at https://www.baptistfirst.org.

Highlights:

Summary The Clinical Documentation Specialist, Team Lead shall be responsible to provide a key role to facilitate long-term success of the clinical documentation improvement and integrity program. This individual will be responsible to increase CDS program awareness with the goal to enhance the appropriateness and comprehensiveness of documentation within the medical record to ensure patient safety and quality of care initiatives. The Team Lead will ensure Physician and allied health documentation accurately represent the condition and co-morbidities for patients. The Team Lead will work in collaboration with clinicians, coding professionals, Physicians, Physician Assistants, and Residents to ensure accurate and timely clinical documentation in the medical record that supports the coding process to have appropriate DRGs based on sound clinical entries in the medical record. This individual will support ongoing communication and education on documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies to Physicians and other hospital staff. In addition, the Team Lead will assist in the maintenance of the CDS dashboard and report outcomes at the monthly CDS Committee Meeting. This individual will mentor staff as the program continues to grow based on identified needs. This position may have additional duties assigned that are within scope of the role.

Education High School diploma or equivalent required. Degree in Nursing preferred. At least 3 years’ experience as a Clinical Documentation Specialist.

License/ Certifications Active RN or LPN licensure required, Certified Documentation Specialist (CCDS) Certification required, in lieu of degree and license must have Certified Coding Specialist (CCS)

Knowledge/ Skills/ Abilities Excellent knowledge of MS Office and familiarity with relevant computer software. Strong team leadership skills, strong organization, interpersonal, and customer relations skills. Must be able to meet strict deadlines. Familiarity with MS-DRGs, Inpatient Prospective Payment System (IPPS), and ICD-10 coding guidelines. Strong analytical and problem-solving ability, and excellent organizational skills. Practical knowledge and understanding of official documentation requirements in support of principal and secondary diagnoses. Must be able to complete multiple tasks simultaneously. Ability to develop trust with leaders in the organizations. Strong written and oral communication skills, proficient computer skills, proven track record of successful performance. Ability to understand complex multifactor situations and bring appropriate solutions. Ability to work both independently and in a team environment.

Primary Location:

Corporate

Job:

Clinical Documentation Specialist Team Leader

Clinical Documentation Improvement Specialist, Team Lead

Job Type:

Regular-Full time

Shift:

First Shift (United States of America)