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RN Team Lead - Clinical Documentation

Company: Baptist Health Care
Location: Pensacola
Posted on: January 24, 2023

Job Description:

Job Description

The Team Lead- Clinical Documentation provides a key role in facilitating long-term success of clinical documentation improvement by providing day-to-day intense oversight of the clinical documentation improvement program at the facility level. This position will work under to ensure accurate and timely clinical documentation in the medical record that supports the coding process in attaining appropriate DRGs based on sound clinical entries in the medical record. This position is responsible for managing the day-to-day operations of the clinical documentation improvement program and ensuring program productivity benchmarks are achieved and maintained. This position will function as a subject matter expert for clinical documentation improvement and support ongoing communication and education on documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies to the team and hospital staff. This position will function as the task force committee chair and participate in steering committee (Administration) meetings.


"Reviews CDS work assignments to ensure equitable workload distribution. Works Clinical Documentation Improvement held bill charts. Manages electronic CDI tool reconciliation process. Assists with managing unanswered Clinical Documentation Improvement post discharge clarifications. Performs concurrent review of charts to ensure 100% of available cases are reviewed. Monitors CDS staff productivity. Monitors partial list in electronic CDI tool for cases not reconciled. Provides quality assurance for electronic CDI tool reconciliation to ensure data accuracy Reviews monthly electronic CDI tool reports with the CDMP Manager Runs individual CDS productivity reports and reviews with each CDS team member Participates as a leader at all Clinical Documentation Improvement meetings and committees Understand and support Clinical Documentation Improvement documentation strategies. Maintains current knowledge/certification.Assist in other duties as assigned to support the operational needs of the department and organization. May be required to remain on campus immediately before, during, and after severe weather and/or disasters."


  • Associates of Nursing degree is required
  • Five years of adult acute care experience in Med/Surg, Critical Care, Emergency Room, or PACU is required
  • Current state Registered Nurse License in the state of Florida
  • Organizational, analytical, writing and interpersonal skills. Excellent knowledge of Word/Excel/Power Point. Knowledge of ICD-10, DRG and other hospital reimbursement methodology (Training provided). Knowledge of regulatory environment.
  • Understand and support Clinical Documentation Improvement documentation strategies
  • Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments

    About Us

    Baptist Health Care is a not-for-profit health care system committed to improving the quality of life for people and communities in northwest Florida and south Alabama. The organization includes three hospitals, four medical parks, Andrews Institute for Orthopaedic & Sports Medicine, and an extensive primary and specialty care provider network. With more than 4,000 team members, Baptist Health Care is one of the largest non-governmental employers in northwest Florida.

Keywords: Baptist Health Care, Pensacola , RN Team Lead - Clinical Documentation, Healthcare , Pensacola, Florida

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