Clinical Document Integrity Specialist Lead | Full time

UF Health • Gainesville, FL

7d

About The Position

This position is responsible for ongoing quality review and assessment of inpatient hospital charts. Performs concurrent and retrospective second level reviews on specific types of opportunities and retrospective requests; cases could include low acuity discharges to hospice and mortalities, low acuity DRGs with long LOS, specific DRG opportunities based on analytics, etc. Prepare reports for management review and identify trends. Strategize approach and process refinements to capture opportunity within the CDS team (prioritization, assignment, etc.) based on retrospective requests and second level reviews. Serve as the main point of contact for external and internal CDI data requests. Under the direction of the Clinical Documentation Integrity Manager, he/she contributes to the development of educational and training opportunities for staff and other duties as assigned.

Requirements

• Graduate of an accredited school of nursing with current RN licensure in the State of Florida or International Medical Graduate with Medical School Diploma required.
• Minimum 5 years of recent clinical experience in a hospital setting.
• Must have strong knowledge of ICD-10 CM/PCS and proficiency with Microsoft Windows Operating Systems and Office applications such as Word, Excel, PowerPoint, and coding/grouping software.
• Able to work well with minimal supervision.
• Able to communicate clearly both written and verbally.
• Able to generate reports for management review that present audit results in a clear manner.
• Able to meet deadlines and respond well to frequent changes in regulation.
• Able to maintain positive and productive relationships with internal and external teams and customers.
• Able to work independently and be a self-starter.
• Registered Nurse (RN) required or Medical School Diploma

Nice To Haves

• Certified Clinical Documentation Specialist (CCDS) preferred certification.
• Utilization Management, Case Management, Quality Improvement or Inpatient Coding experience preferred.

Responsibilities

• Ongoing quality review and assessment of inpatient hospital charts
• Performs concurrent and retrospective second level reviews on specific types of opportunities and retrospective requests
• Prepare reports for management review and identify trends
• Strategize approach and process refinements to capture opportunity within the CDS team (prioritization, assignment, etc.) based on retrospective requests and second level reviews
• Serve as the main point of contact for external and internal CDI data requests
• Contributes to the development of educational and training opportunities for staff and other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees