Clinical Documentation Integrity Specialist I

Sarasota Memorial Health Care System • Sarasota, FL

37d

About The Position

The Clinical Documentation Integrity Specialist is responsible for facilitating the improvement and overall quality and completeness of clinical documentation to support coding in the inpatient setting, and will be responsible for reviewing inpatient medical records including daily admissions while the patient is still in-house (concurrent), as well as, subsequent reviews until discharge. The Specialist is also responsible for querying physicians on specificity of diagnosis or procedures performed in order to ensure the account appropriately reflects the patient's Severity of Illness (SOI), Risk of Mortality (ROM), and resources used to care for the patient resulting in complete and accurate profiling and reporting outcomes. In addition, the Specialist will provide documentation and coding education as needed.

Requirements

• Require a Bachelor's degree (preferably BSN). Associate degree in Nursing (ASN) and two (2) years of relevant clinical work experience in an acute care inpatient setting can substitute for required degree.
• Require a minimum of three (3) years of experience in nursing or other relevant clinical area, coding, or utilization review/case management in an acute care facility.
• Require an active Florida Registered Nurse (RN) license or Medical Doctor (MD) equivalent.

Nice To Haves

• Prefer effective interpersonal skills in order to interact effectively with all levels of hospital personnel.
• Prefer demonstrated prioritization, organization and analytical skills.
• Prefer demonstrated effective written and verbal communications skills.
• Prefer demonstrated proficiency with Microsoft Office and related software packages.
• Prefer coding skills with experience in ICD-10-CM and working knowledge of the AHA Coding Clinic.
• Prefer Certified Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement Practitioner (CDIP) certification.
• Prefer coding certification from the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC).

Responsibilities

• Facilitating the improvement and overall quality and completeness of clinical documentation to support coding in the inpatient setting
• Reviewing inpatient medical records including daily admissions while the patient is still in-house (concurrent), as well as, subsequent reviews until discharge.
• Querying physicians on specificity of diagnosis or procedures performed in order to ensure the account appropriately reflects the patient's Severity of Illness (SOI), Risk of Mortality (ROM), and resources used to care for the patient resulting in complete and accurate profiling and reporting outcomes.
• Provide documentation and coding education as needed.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Hospitals
• Number of Employees: 5,001-10,000 employees