Teams at Northeast Georgia Health System

Improves clinical documentation accuracy and completeness through concurrent and discharge reviews, physician queries, DRG analysis, coding collaboration, and education. Ensures documentation supports appropriate reimbursement, medical necessity, quality measures, and outcome reporting. Works with physicians, nurses, case managers, coders, and CDI staff while addressing documentation gaps, patient safety indicators, and utilization concerns. The role requires an experienced Georgia-licensed RN with strong clinical, analytical, communication, and leadership skills.

Provides senior-level expertise in hospital revenue integrity, charge capture, CDM application, compliance, and reimbursement. Leads audits, identifies revenue loss risks, analyzes financial impacts, supports CPT and HCPCS updates, and develops corrective actions. Partners with clinical, coding, IT, finance, compliance, and leadership teams to optimize workflows and revenue. Creates dashboards, delivers recommendations, and leads training and governance initiatives while ensuring CMS and payer compliance.

Audits clinical documentation, performs second-level CDI reviews, and supports documentation improvement initiatives. Educates and trains CDI staff, physicians, and healthcare teams; manages onboarding and continuing education; monitors productivity, core measures, patient safety indicators, and reporting accuracy. Collaborates with HIM, coding, patient safety, and clinical teams to improve documentation, coding compliance, workflow effectiveness, and data quality. Functions as a Clinical Documentation Specialist when not conducting educational activities.