Clinical Document Integrity Specialist - RN | Full Time | Day Shift
About The Position
Responsible for facilitating improvement in inpatient clinical documentation through concurrent review of the medial record for accurate physician documentation of diagnoses based on clinical evidence present in the chart, application of official ICD-10-CM coding guidelines, and interaction with physicians and other clinicians. Identifies opportunities for improvement in clinical documentation and queries the physician for clarification to support more specific diagnoses. Collaborates with physicians and coders to obtain documentation that most accurately reflects patient’s severity of illness and risk of mortality. Educates all members of the patient care team on an ongoing basis.
Requirements
- Graduate of an accredited school of nursing with current Registered Nurse (RN) licensure in the State of Florida, OR
- Advanced Medical Practitioner, OR
- International Medical Diploma
- Minimum of 3 years of recent clinical experience in a hospital setting
- Registered Nurse (RN) license in the State of Florida required, OR
- Advanced Medical Practitioner, OR
- International Medical Diploma
- Employees in this position: Will operate vehicles for an assigned business purpose as a non-frequent driver
Nice To Haves
- Certified Clinical Documentation Specialist (CCDS) preferred
- Experience in Utilization Management, Case Management, Quality Improvement, or Inpatient Coding preferred
Responsibilities
- Facilitating improvement in inpatient clinical documentation
- Concurrent review of the medial record for accurate physician documentation of diagnoses based on clinical evidence present in the chart
- Application of official ICD-10-CM coding guidelines
- Interaction with physicians and other clinicians
- Identifies opportunities for improvement in clinical documentation
- Queries the physician for clarification to support more specific diagnoses
- Collaborates with physicians and coders to obtain documentation that most accurately reflects patient’s severity of illness and risk of mortality
- Educates all members of the patient care team on an ongoing basis
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
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
