Lead Clinical Documentation Specialist

Arkansas Children’s Hospital


The Lead Clinical Documentation Specialist is responsible for the day-to-day operation of the clinical documentation improvement functions in the Health Information Management Department. Works closely with the Director of Health Information Management in implementation of departmental goals and actions plans. Responsible for review and feedback to clinical documentation specialists on review and query practices

Job Description:

Primary Duties and Responsibilities

1. Department and Project Management

  • Demonstrates an understanding of the operational and strategic linkage between one segment of the organization with other segments.
  • Works with Director to implement and evaluate departmental goals and action plans which support the hospital mission, philosophy and strategic plan.
  • Completes responsibilities in a timely manner through effective organization, setting priorities, delegation, and time management skills.

2. Technical Knowledge, Skill Level

  • Works closely with coding staff and clinical documentation specialists to ensure CDI staff are assigning appropriate codes and CCs for SOI/ROM.
  • Performs productivity and quality assessments of individual CDI Specialists on at least a monthly basis.
  • Works with Coding Manager to maintain current coding updates, processes and educates CDI Specialists on these as they occur.
  • Prepares and submits monthly CDI program status to the HIM Director.
  • Demonstrates a thorough understanding of the MS-DRG/APR-DRG system, CCs/MCCs, and SOI/ROM impact on quality and case mix index for optimal benchmark and outcome data.
  • Provides feedback, assists in coordinating and/or facilitating focused educational strategies regarding CDI program objectives and best practices for documentation improvement to CDI staff.

3. Human Resources Management

  • Develops and maintains a staffing plan for the clinical documentation area.
  • Assists with recruiting and interviews. Orients and trains qualified CDI staff in accordance with ACH policies and procedures.
  • Assist Director with managing performance by assessing staff competency and providing constructive feedback on initial hire and on an ongoing basis and during annual performance appraisals.
  • Evaluates needs, assigns and directs staff to prioritize and coordinate service responsibility on a day-to-day basis.
  • Evaluates educational needs for areas of responsibility and works with and makes recommendations to Director regarding meeting those needs.


4. Fiscal Management and Resource Utilization

  • Plans, develops, monitors, and assumes accountability for operating within the annual departmental and capital equipment budget for areas of responsibility.
  • Monitors, reviews, justifies, and implements strategies to improve financial performance for assigned areas including expenses and productivity.


5. Leadership

  • Oversees the operations of clinical documentation program.
  • Participates in the hiring, corrective action and annual performance review processes.
  • Serves as a role model and mentor for assigned staff by consistently demonstrating professionalism.
  • Assumes responsibility for professional development and integration of acquired knowledge and skills into practice.

Experience Requirements:

Required – 4 years total experience required, which includes 2 years of clinical documentation experience experience, which includes 2 years of Clinical Nursing experience

Certification/License/Registry Requirements:

Required – RN License (AR or Compact State) (Candidate must possesss at time of hire)
Required – Certified Documentation Improvement Practitioner (CDIP) (Certification)or Certified Clinical Documentation Specialist (CCDS) (Certification) (needed within 2 years of hire date)

Preferred Experience:

1 years Supervisory or Lead experience preferred

Preferred Certification:

National Coding Certification

Education Qualifications:

Required – Bachelor’s degree from four-year college or university – Field of Study: Nursing

Apply Online: http://www.archildrens.org