Quality & Improvement Nurses - Baystate Health

Req#: R27021
Category(s): Nursing, Quality & Improvement Nurses
Full Time / Part Time: Full-Time
Shift: First


The Clinical Documentation Specialist Lead provides a second level of support, as directed by the Manager/Director, to the daily activities and responsibilities of the Clinical Documentation Specialists. Must be able to resolve issues effectively and provide recommendations and solutions. This is a working lead position; lead duties may include many of the following: organizing work schedules, making work assignments, conducting quality assurance audits of staff performance, training, and mentoring staff, providing feedback on staff performance and developmental needs, lead and regularly perform special projects, collect/analyze/report on data, and other responsibilities of a similar nature.

The CDI Lead follows and adheres to all job requirements and expectations included here and those also listed in the Clinical Documentation Specialist job description.       

Functions as subject matter expert and actively participates in CDI department meetings as a problem-solver. Will develop, deliver, and present materials to promote awareness and understanding of documentation needs and requirements to providers and hospital staff. Will aid in the analysis of reporting to determine opportunities for case mix index improvement, value-based, and other quality-based efforts. Is a supportive team member with the ability to deliver information in multiple communication formats clearly, concisely, and respectfully.

Job Requirements:

1) Will perform supportive daily concurrent reviews

2) Coordinates daily operations and directives with CDI Manager/Supervisor

3) Will assist with and develop physician queries adhering to AHIMA/ACDIS and other regulatory guidelines

4) Is a dedicated mentor and supportive lead to designated team members

5) Will develop educational materials using PowerPoint, newsletters, tip cards, emails, department intranet pages, and video

6) Working closely with the CDI Specialists, identify areas of non-specific documentation and improve documentation templates in support of clinical treatment protocols.

7) Collaborate with CDI Manager and other clinicians to facilitate the ongoing relevance of department-specific orientation content, educational materials and documentation tip sheets, and training programs/resources.

8) Assist with the development and editing of policies and procedures and leading and attending team meetings.

9) Conduct individual and large group educational sessions for all CDI Specialists and/or providers.

10) Supports and mentors new onboarding CDI specialists

11) Conducts quality audits

12) Is responsible for final DRG data quality reconciliations

13) With the CDI Manager facilitates project activities to meet timelines, expectations, and outcomes.

Minimally Required Education:

Associate's Degree – RN, MD, or CCDS

Preferred Education:

Bachelor's Degree

Minimally Required Experience:

5 years in an acute care setting; If Physician trained experience, RN will not be required

Preferred Experience:

Previous leadership experience


Extensive clinical knowledge and understanding of pathology/physiology, best demonstrated by clinical experience in the hospital setting

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.



Assoc of Science in Nursing: Nursing (Required), Bachelor of Nursing Degree


Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

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