Clinical Documentation Integrity CDI - Nurse Educator
Northeast Georgia Health System, Inc.

Job Info

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Improving the health of our community in all we do

Northeast Georgia Health System (NGHS)is a non-profit community health system on a mission of improving the health of our community in all we do. Our team cares for more than 1 million people across the region through four hospitals and a variety of outpatient locations. Northeast Georgia Medical Center (NGMC) has campuses in Gainesville, Braselton, Winder and Dahlonega - with a total of more than 700 beds and more than 1,100 medical staff members representing more than 50 specialties. NGHS also encompasses Northeast Georgia Physicians Group, a multi-specialty group with more than 65 locations, and The Heart Center of Northeast Georgia Medical Center, a cardiology practice with more than 15 locations.

NGHS

Clinical Documentation Integrity CDI - Nurse Educator

Full Time

Job Summary:

Participates in the daily activities of the Clinical Documentation Department. Facilities modifications to clinical documentation to ensure accurate depiction of the level of clinical services and patient severity actively present during the patient's encounter. Is responsible for orientation, training and education of CDI staff and supports provider education development and execution. Is knowledgeable of program metrics, serves to ensure data is timely and accurately reported. Understands the CDI/ Coding data base and ensures optimization of 3M-360 applications. Assesses learning needs of CDI Nurses, Physicians, administration in regard to CDI workflow and output.

Minimum Job Qualifications:

• Registered Nurse licensed to practice in the State of Georgia.
• Clinical Documentation Specialist Certification Required (CCDS).
• Coding Experience Preferred.
• 3-5 years clinical nursing experience preferably in critical care nursing.
• 3-5 years clinical documentation experience

Preferred Education requirements:

• Bachelor's Degree

Job Specific and Unique Knowledge, Skills and Abilities

• Comprehensive knowledge in acute med-surg nursing.
• Must be comfortable operating independently in a collaborative, shared leadership environment.
• Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Ability to educate all members of the healthcare team related to clinical documentation.
• Excellent computer skills, including MS Office applications. Experience with databases, spreadsheets/presentation software.
• Possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivates others to promote the philosophy, mission, vision, goals and values of the Organization.
• Ability to develop and implement a strategic direction and vision.
• Ability to work collaboratively with diverse groups and to effectively persuade and lead individuals/groups towards consensus.
• Advanced analytical skills in areas of health information workflow analysis and planning combined with the ability to form meaningful conclusions and present complex data in an understandable format.
• Demonstrates knowledge of the fundamentals of hospital organization/administration and the laws applicable to health information management and CDI.
• Knowledge of Medicare Part A and Part B with the ability to understand and communicate differences between Part A and Part B guidelines.

Essential Tasks and Responsibilities

• Provides day-to-day educational support for clinical documentation program priorities.
• Function in the capacity of Clinical Documentation Specialist when not involved in educational activities.
• Reviews CDS productivity reports and reviews with each CDS team member on a quarterly basis.
• Manage process flow and oversees the communication and education plan, including on-boarding of new staff, continued education for current staff, and on-going physician education.
• Manage the reconciliation process, ensuring CDS staff are performing task correctly and provide quality assurance to promote data accuracy.
• Coordinate and works effectively with other Clinical Documentation Specialists.
• Perform internal audits for CDI feedback and performance improvement opportunities.
• Provide physician education at Department meetings creating tip sheets, pocket cards, and other tools; support Director via education to ensure fully informed and engaged medical staff.
• Support Director to track metrics, assess ICD-10 Compass, and 3M profile reports to create charts/graphs for presentation to Executive staff and Physician leadership.
• Support Director and 3M Application Analyst to ensure optimization of 3M 360 tool.
• Communicate concise, understandable terms with all people involved in the development and implementation of applications both orally and in writing.
• Partner with Director's of HIM and Clinical Documentation Specialist in education development and training for ICD-10.
• Monitor documentation again "ore measure" quality indicators and addresses documentation opportunities with Physicians, Advanced Health Practitioners, and other appropriate staff.

Since first opening its doors in Gainesville in 1951, Northeast Georgia Medical Center has added hospital campuses in Braselton, Barrow and Dahlonega - and become Georgia's most awarded hospital. Some recognitions include being named to these lists:

America's 50 Best Hospitals- Healthgrades

100 Top Hospitals- Truven Health Analytics

100 Hospitals with Great Heart Programs- Beckers Hospital Review

America's Top Quality Providers- Carechex

Atlanta's Top 150 Workplaces- Atlanta Journal-Constitution

Healthcare's Most Wired Hospitals and Health Systems- Hospitals & Health Networks magazine

NGMC has also been recognized in recent years as Georgia's #1 Hospital for overall hospital care, overall surgical care, heart care, orthopedic surgery, women's care and more.

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