Clinical Documentation CDI Educator / Auditor RN - CCDS REQUIRED - Mon - Fri 8:00am - 4:30pm

20 Northeast Georgia Medical Center, Inc.; Georgia; Hybrid; USD 90,000 - 115,000; Full time

Job summary

Northeast Georgia Health System is seeking an Auditor-CDI Nurse Educator to support the Clinical Documentation Department by leading education, audits, and provider training to improve documentation accuracy and patient severity depiction during encounters.

The role requires a GA RN license, CCDS certification, a Bachelor’s degree, 5–10 years of nursing experience, and 3–5 years in clinical documentation, with strong communication and data analysis skills.

Qualifications

• Current Registered Nurse license in GA.
• Clinical Documentation Specialist (CCDS) certification.
• Bachelor's degree in a relevant field.
• 5–10 years nursing experience; 3–5 years CDI experience.

Responsibilities

• Provide day-to-day educational support for clinical documentation priorities.
• Function as Clinical Documentation Specialist when not teaching.
• Review productivity reports and conduct quarterly CDI feedback sessions.
• Coordinate onboarding and ongoing physician and staff education on coding guidelines.
• Collaborate with HIM leadership to improve documentation quality and data reporting.

Skills

Clinical documentation

Nurse educator

Data analysis

Education delivery

Cross-team collaboration

Education

Bachelor's Degree

CCDS certification

RN license GA

Master's Degree

Tools

MS Office

3M-360

Job description

Job Category: Nursing - Registered Nurse Work Shift/Schedule: 8 Hr Morning - Afternoon

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role

Posting Details Job Summary The Auditor-CDI Nurse Educator participates in the daily activities of the Clinical Documentation Department and facilitates documentation improvements to ensure accurate depiction of clinical services and patient severity actively present during patient encounters. The Auditor-CDI Nurse Educator performs department audits, 2nd level reviews, orientation, training and education of CDI staff and supports development of focused provider education. Maintains knowledge of program metrics and helps support timely, accurate data reporting. The Auditor-CDI Nurse Educator contributes to the effective use of 3M-360 applications by accessing and identifying learning needs of CDI nurses, residents, physicians, and administrative staff.

Minimum Job Qualifications

• Licensure or other certifications: Current Registered Nurse license in State of GA.
• Certification required - Clinical Documentation Specialist (CCDS).
• Educational Requirements: Bachelors Degree.
• Minimum Experience: Five (5) to ten (10) years clinical nursing experience.
• Three (3) to five (5) years experience clinical documentation experience.

Preferred Job Qualifications

• Preferred Licensure or other certifications: Preferred Educational Requirements: Masters Degree.
• Preferred Experience: Coding.
• Five (5) to ten (10) years clinical nursing experience in critical care nursing.
• Management experience desirable.

Job Specific and Unique Knowledge, Skills and Abilities

• Comprehensive knowledge in acute med-surg, critical care, cardiology nursing.
• Must be comfortable operating independently in a collaborative, shared leadership environment.
• Excellent communication (verbal and written), interpersonal, collaboration skills.
• Demonstrates critical thinking, effective prioritization and organization skills, and the ability to education the healthcare team on clinical documentation.
• Excellent computer skills, including MS Office applications.
• Experience with databases, spreadsheets/presentation software.
• Ability to develop and implement a strategic direction and vision for project management & priority of work.
• 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.
• Communicate concise, understandable terms with all people involved in the development and implementation of applications both orally and in writing.

Essential Tasks and Responsibilities

• Provide 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 meets quarterly with each CDS team member; manages the reconciliation process to ensure tasks are completed accurately and timely; and conducts internal audits to provide CDI feedback, promote data accuracy, and identify performance improvement opportunities.
• 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.
• Coordinate and works effectively with other Clinical Documentation Specialists, CDI Associate, Admin Support and Manager Partner with Director's of HIM and Clinical Documentation Specialists in education development and training for coding guidelines.
• Monitor documentation against "core measure" quality indicators and address documentation opportunities with Physicians, Advanced Health Practitioners, and other appropriate staff.
• Collaborate with patient safety team and coding to maintain accuracy in codes associated with patient safety indicators (PSIS).

Physical Demands

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time.
• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time.
• Vision: Heavy, Constantly 66-100% of time.
• Kneeling/Stooping/Bending: Occasionally 0-30%.
• Standing/Walking: Occasionally 0-30%.
• Pushing/Pulling: Occasionally 0-30%.
• Intensity of Work: Occasionally 0-30%.

Job Requires

• Reading, Writing, Reasoning, Talking, Keyboarding, Driving.

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.

Northeast Georgia Health System (NGHS) is a non-profit 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 five hospitals and a variety of outpatient locations. Northeast Georgia Medical Center (NGMC) has campuses in Gainesville, Braselton, Winder, Dahlonega and Demorest – with a total of more than 850 beds and more than 1,200 medical staff members representing more than 60 specialties.

Learn more at www.nghs.com.