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Registered Nurse, RN | Lead Clinical Documentation Specialist

Gundersen Health System • Full-time • Home - Wisconsin, United States of America • 1w ago

Love + medicine is who we are, it's what we do, it's why people want to work here. If you’re looking for a job to love, apply today.

Schedule Weekly Hours:

Bellin Gundersen Health System is looking for a full-time RN (1.0 FTE) to work as a Lead, Clinical Documentation Specialist.

What you will do:

Lead both the Bellin and Gundersen CDI teams
Work under the direction of the Clinical Documentation Improvement (CDI) Supervisor to design, develop, implement and operate the quality control and monitoring program for inpatient and ambulatory CDI program
Inpatient CDI staff training and development, measures of efficiency and effectiveness, quality control and improvement.
Monitor and measuring compliance with coding guidelines, optimizing DRG, providing or arranging for training and continuing education of CDI specialists.
Oversee scheduling and daily CDI work

What you will get:

No work on weekends and holidays
Top-rated retirement and healthcare benefits
Support to grow your career with access to our Career Development Center and Tuition Investment Program
Have your voice heard through our Nursing Shared Governance Councils

What you need:

Bachelor’s Degree in Nursing
3 years of inpatient CDI experience and demonstrated leadership of a team or project with positive results
Prefer 5-7 years of inpatient CDI experience and demonstrated leadership of a team or project with positive results
RN licensure to practice in the state of Wisconsin upon hire.
CCDS/CCDS-O or CCS certification within 24 months of hire

At Bellin Gundersen, we believe in leading with love and fostering a culture of belonging and excellence. If you share our values, we invite you to submit your application.

ONE SYSTEM, ONE VISION: Bellin Gundersen Health System is a large and growing health system with a strong presence in the region. We operate 11 hospitals, more than 100 clinics, and employ over 14,000 teammates across 35 counties in 4 states.

Job Description:

The RN, Lead Clinical Documentation Specialist (CDS) works under the direction of the Clinical Documentation Improvement (CDI) Supervisor to design, develop, implement and operate the quality control and monitoring program for inpatient and ambulatory CDI program. Scope of work includes inpatient and ambulatory CDI staff training and development, measures of efficiency and effectiveness, quality control and improvement. Uses clinical experience as well as expert knowledge of ICD-10 Official Guidelines for Coding and Reporting, AHA Coding Clinic, DRG grouping schemes, HCC capture and CDI knowledge to assist the Supervisor by monitoring and measuring compliance with coding guidelines, optimizing DRG and HCC reimbursement, providing or arranging for training and continuing education of CDI specialists. Oversees scheduling and assigns daily CDI work. Lead will assist with external audit and denial work. Maintains hospital and clinic coding proficiency and periodically review hospital inpatient and ambulatory CDI records. Achieves and maintains proficiency in ICD-10-CM and ICD-10-PCS. Partners with Information Systems to maintain, upgrade and trouble shoot the applications, technology and resources used daily by the Inpatient and Ambulatory RN CDS.

Major Responsibilities:

1. Implement the department’s quality control and assurance program. Perform internal audits to ensure staff compliance with coding and reimbursement guidelines. In coordination with supervisor, assess each inpatient and ambulatory RN CDS’s adherence to ICD-10 CM and/or PCS coding conventions, the AHIMA Standards of Ethical Coding and the ACDIS Code of Ethics.

2. Monitor staff compliance with provider query polices to acquire documentation which supports appropriate procedure and diagnosis codes. Assess the adequacy of documentation to support code assignment. Escalate documentation issues according to departmental policy.

3. Maintain an expert level of CDI knowledge. Serve as an information resource for coding staff, CDI staff and providers.

4. Provide individual employee feedback and coaching as directed by Supervisor to achieve and sustain individual, department, and organizational goals. Summarize employee performance regularly and contribute to the supervisor's performance appraisal of the inpatient and ambulatory RN CDSs. Ensure staff has accessibility and understanding of tools and resources in order to effectively perform their work and achieve goals.

5. Monitor rounding practices of inpatient RN CDI specialists.

6. Under the direction of the supervisor, assist with delivering, monitoring, and maintaining the orientation, training, and staff development activities and materials for CDI RNs at Gundersen Health System.

7. Partner with CDI leaders to develop, implement, and maintain department policies and procedures. Identify and initiate updates or new polices or procedures. Assist in the annual review of all department/section policies.

8. Collaborate with CDI leadership to identify, evaluate, recommend, and obtain tools to support employees in their daily work such as reference material, staff development resources, and technology. Review, evaluate and recommend software applications that will enhance the efficiency and accuracy of code assignment.

9. Participate in interviewing candidates for open positions.

10. Performs other job-related responsibilities as requested.

Education and Learning:

REQUIRED

Bachelor's degree in Nursing

Work Experience:

REQUIRED

3-4 years of inpatient CDI experience and demonstrated leadership of a team or project with positive results.

DESIRED

5-7 years of inpatient CDI experience and demonstrated leadership of a team or project with positive results.

License and Certifications:

REQUIRED

Registered Nurse (RN) licensed minimally in the state of practice, some positions may require additional state RN licenses

CCDS/CCDS-O (Certified Clinical Documentation Specialist/Certified Clinical Documentation Specialist-Outpatient) or CCS (Certified Coding Specialist) within 24 months of hire

DESIRED

Certified Clinical Documentation Specialist (CCDS) or Certified Coding Specialist (CCS)

Age Specific Population Served:

Nonage Specific (N/A)

OSHA Category:

Category III - No employees in this job title have a reasonably anticipated risk of occupational exposure to blood and/or other potentially infectious materials.

Environmental Conditions:

Exposed to infectious diseases.

Physical Requirements/Demands Of The Position:

Sitting Frequently (34-66% or 5.5 hours)

Walking/Standing Frequently (34-66% or 5.5 hours)

Repetitive Actions - Fine Manipulation Frequently (34-66% or 5.5 hours)

If you need assistance with any portion of the application or have questions about the position, please contact HR-Recruitment@gundersenhealth.org or call 608-775-0267

Equal Opportunity Employer

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