Lead Clinical Documentation Improvement (CDI) RN

ech Observer has been providing Staffing(Clinical/Scientific/IT/Professional) and Clinical Research Services since 2005. We have offices in New Jersey: US (Headquarters), India ,UK, Denmark and Singapore. Being ISO 9001:2008, ISO 14155:2011 and ISO 27001 certified company, we believe in quality & responsible work ethic. We are proud in providing strategic & real-time insights to the client to achieve their goals. Our services range offer flexible solutions to our clients ranging from ‘standalone service’ to ‘end to end support’ for their needs. With a team of 500 employees globally, we are serving more than 50 companies in over 30 countries. Our Key Services are: • Clinical Operations • Clinical Data Management • Biostatistics & SAS Programming • Medical Writing & Scientific Communications • Post-Marketing Clinical Studies • Staffing (US only)

Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure that compliant documentation is achieved, with resultant appropriate level of severity reflected and reimbursement received for service rendered to all patients with a DRG based payor.

Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Assists the Case Management Manager in the day to day responsibilities of overseeing the Documentation Specialists. Includes, but is not limited to, participation in the Documentation Specialist performance appraisal process, supervision of workload assignments, and practice supervision. Plans and implements compliant documentation goals and objectives across the Community Hospital Division (CHD), which support hospital goals and objectives. Assists in development of agendas and in material preparations for meetings to support hospital improvements in identified hospital initiatives, including CDE System Steering Committee. Coordinates and manages program reporting and outcome measurements. Assists the Case Management Manager in the development and updating of policies, procedures and workflow. Facilitates modifications to clinical documentation to ensure compliant documentation with appropriate reimbursement received for the level of service rendered to all patients with a DRG based payor. Improves the overall quality and completeness of clinical documentation, ensuring documentation integrity, by performing initial reviews, continued stays reviews and reconciliation process using the 3M 360 Program. Coordinates professional growth for the Community Hospital Division - RN Clinical Documentation Specialists through appropriate educational opportunities. Coordinates staff development activities related to education, quality assurance and outcome measurements. Coordinates staff development activities related to education, quality assurance and outcome measurements. Facilitates communication and confers with providers face to face or via Clinical Documentation Excellence (CDE) Shared Note to clarify diagnoses information, obtain needed documentation, present opportunities and educate for appropriate DRG based on severity of illness (SOI) and risk of mortality (ROM). Reviews patient record to ensure points of clarification have been recorded. Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies. Assists with staff recruitment and interviewing RN Clinical Documentation Specialists ( CDS) candidates. Serves as Primary lead for orientation and training for new RN CDS. Assists with management of 3M 360 program and serves as subject matter expert with IT on resolution. when operations impacted. Other duties as assigned.