RN Clinical Documentation Integrity Specialist Flex shift

Overview

The Clinical Documentation Specialist conducts medical record reviews and identifies documentation needs within the medical record. The position also communicates, either verbally or in writing, with health care providers to address those needs in the medical record.

Clinical Documentation Specialist – Key Responsibilities

• Facilitates and obtains appropriate physician documentation for all clinical conditions and procedures to accurately reflect the patient’s
  severity of illness
  ,
  risk of mortality
  , and
  complexity of care
  .
• Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional details within the health record as needed.
• Completes initial reviews of patient records within
  24–48 hours of admission for an assigned patient population to:
• Evaluate documentation to assign the
  principal diagnosis
  ,
  pertinent secondary diagnoses
  , and
  procedures for accurate
  DRG assignment
  ,
  risk of mortality
  , and
  severity of illness
  .
• Initiate and maintain a
  review worksheet for each case.
• Conducts follow-up reviews every2–3 days to support and confirm a
  working or final DRG assignment upon patient discharge, as necessary.
• Utilizes the
  Concurrent Query Structured Note in Allscripts to issue physician queries.
• Processes documentation queries requested by the
  coding department
  .
• Educates physicians and key healthcare providers on clinical documentation improvement (CDI) principles and the importance of accurate and complete documentation in the health record.
• Collaborates with case managers, nursing staff, and other ancillary team members to communicate and resolve documentation issues or physician queries
  prior to patient discharge when possible.
• Assists in preparing and presenting clinical documentation
  monitoring and trending reports for review with physicians and hospital leadership.
• Educates patient care team members regarding specific documentation requirements,
  reporting and reimbursement issues
  , and findings identified through daily and retrospective reviews or aggregate data analysis.
• Performs other duties as assigned by the department.

• Minimum Requirements
• Education: Graduate of an accredited school of nursing
• Experience: Five (5) to seven (7) years of acute nursing care experience in a hospital environment
• Licensure/
  
  Certifications:
  
  Active Florida Registered Nurse (RN) license
• Preferred Qualifications
• Experience: Clinical Documentation Improvement (CDI) and/or ICD-10 coding experience
• Certifications: Certified Clinical Documentation Specialist (CCDS)
• Additional Information
• Certification Requirement: CCDS certification must be obtained within four (4) years of hire or transfer date.