Registered Nurse Clinical Documentation Specialist

Ascension•Panama City Beach, FL

2d•$84,061 - $118,669•Hybrid

About The Position

This role is responsible for completing admission reviews and assigning a working Diagnosis Related Group (DRG). The specialist will ensure the working DRG and other relevant information are entered into the Clinical Documentation Improvement (CDI) database. A key aspect of this position involves initiating and maintaining extensive interactions with physicians and mid-level providers to ensure the medical record contains sufficiently detailed information. The specialist will collaborate with healthcare professionals to accurately reflect the severity of illness and level of services provided in the medical record, and to resolve physician queries and documentation issues before patient discharge. Maintaining accurate records of review activities and ensuring the validity of reports and outcomes of CDI efforts are also crucial responsibilities.

Requirements

Registered Nurse credentialed from the Florida Board of Nursing obtained prior to hire date or job transfer date required.
Licensed as a Registered Nurse in Florida required.
Credentialed from State Board of Nursing or current home state license for multi-state license recognition "Compact State" obtained prior to hire date or job transfer date required.
Diploma from an accredited school/college of nursing OR Required professional licensure at time of hire.
5+ years ICU and Med Surg experience

Nice To Haves

CDI experience preferred
CCDS preferred

Responsibilities

Complete admission reviews and assign a working Diagnosis Related Group.
Ensure the working DRG and other information are entered in the Clinical Documentation Improvement database.
Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.
Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge.
Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.