Clinical Documentation RN Specialist (Full Time, Days)

Nicklaus Children's • Miami, FL

18d • Onsite

About The Position

Responsible for leading comprehensive clinical documentation audits to ensure accuracy, compliance, and alignment with regulatory and organizational standards for Emergency Services. Primary responsibilities include conducting focused and routine audits across key clinical domains, including sepsis, restraints, triage, sedation, discharge process, weight discrepancies, and assessment/reassessment compliance. Through detailed chart reviews, identifies gaps and documentation discrepancies that impact both clinical quality outcomes and appropriate charge capture. Actively works to mitigate missed revenue opportunities by ensuring accurate facility charge codes within the appropriate timeframe. Maintains clinical competency by working a minimum of one bedside shift per week to ensure strong alignment with frontline workflows and real-time documentation practices. Promotes a culture of accountability, continuous improvement and regulatory readiness by supporting audit readiness efforts and assisting leadership in monitoring performance against key quality and compliance metrics. Acts as a resource to staff and leadership, fostering strong professional relationships and consistently demonstrating excellence in service.

Requirements

• Bachelor's Degree BSN
• RN Licensure within the State of Florida or Multi-State Enhanced Nursing License Compact (eNLC) – maintain active and in good standing throughout employment
• American Heart Association BLS - maintain active and in good standing throughout employment
• American Heart Association PALS required within 2 years of hire - maintain active and in good standing throughout employment
• Crisis Prevention Institute (CPI) required within 1 year - maintain active and in good standing throughout employment
• 3-5 years of clinical RN experience
• 1-3 years of experience in clinical documentation review, charge capture and revenue integrity.
• Proficiency in computers and Electronic Medical Record (EMR).
• Effective verbal and written communication skills.
• Ability to positively influence, hold self and others accountable.
• Able to work effectively in collaborative environment.
• Demonstrate problem solving skills.
• Ability to maintain confidentiality of sensitive information.
• Outstanding analytical and organizational skills with attention to detail.
• Able to analyze and interpret data and utilize the information to make judgments regarding patient care.

Nice To Haves

• Nursing experience in a pediatric healthcare setting is strongly preferred.

Responsibilities

• Conducting focused and routine audits across key clinical domains, including sepsis, restraints, triage, sedation, discharge process, weight discrepancies, and assessment/reassessment compliance.
• Identifying gaps and documentation discrepancies that impact both clinical quality outcomes and appropriate charge capture through detailed chart reviews.
• Mitigating missed revenue opportunities by ensuring accurate facility charge codes within the appropriate timeframe.
• Maintaining clinical competency by working a minimum of one bedside shift per week.
• Promoting a culture of accountability, continuous improvement and regulatory readiness by supporting audit readiness efforts and assisting leadership in monitoring performance against key quality and compliance metrics.
• Acting as a resource to staff and leadership, fostering strong professional relationships and consistently demonstrating excellence in service.
• Educating and providing consultation services to clinical staff in reference to documentation and charge capture process, procedures, concerns and issues.
• Assessing the accuracy of medical records documentation to ensure it supports the diagnoses, conditions, problems or other reasons for the visit.
• Identifying documentation trends and deficiencies, and developing and disseminating education for nursing staff improvement.
• Developing PowerPoint presentations and presenting material at staff meetings.
• Instructing and coaching employees with charge entry and documenting audits.
• Posting accurate patient specific charges to the system within 3 business days of service to ensure timely billing.
• Performing daily charge reconciliation and procedure appropriate for respective department.
• Acting as a resource to NCHS leaders regarding documentation and department charge processes.
• Remaining current with healthcare trends.
• Updating standard operating procedure for facility charges in the department.
• Reviewing and maintaining quality measures for clinical documentation and charge capture.
• Coordinating trainings for charge process and accuracy.
• Communicating to department leadership and Revenue Integrity compliance of documentation review and findings.
• Serving as a liaison between department, nursing and physician leadership, Revenue Integrity, and Health Information Management.
• Meeting or exceeding unit standards in achieving hospital-wide CEI/SEI; completing documentation in a timely manner, & being accountable to regulatory requirements of the DNV & other accrediting agencies.
• Performing all RN Emergency Services duties, including but not limited to, completing a comprehensive multi-system assessment that includes Cardiac, Respiratory and Neurological.
• Developing a plan of care and conducting reassessments.
• Providing care such as starting/monitoring IV’s, specimen collection, POC testing, medication administration, and assisting medical team with other procedures and promoting an “error-free” working environment by consistently providing high-quality safe care as prompted including sedation as required per policy.
• Ensuring accurate completion of triage documentation including vital signs and patient history as per department and hospital policies and procedures.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level