RN, Clinical Doc Int Spec Lead| Clinical Documentation Improvement| Day | Full Time

UF Health•The Villages, FL

About The Position

Leads the process of maintaining the accuracy and completeness of clinical documentation to support patient care and regulatory compliance. Reviews clinical records to identify gaps, collaborates with healthcare providers to enhance documentation quality, and develops improvement strategies and training programs. Monitors regulatory changes, leads audits and quality assurance activities, and facilitates communication between clinical teams and coding specialists. Reports findings and recommends corrective actions to uphold documentation standards and integrity.

Requirements

Diploma or associate's degree in nursing; a bachelor's degree is preferred.
Florida Registered Nursing or Advanced Practitioner license/certification/registration.
Florida driver's license required.
5+ years' experience leading clinical documentation improvement programs.
Expertise in regulatory compliance and audit management.
Proven ability to develop training programs and improvement strategies.
Strong skills in cross-functional team leadership and communication.
Experience monitoring documentation quality and reporting outcomes.

Nice To Haves

Bachelor's degree in nursing.
Certified Clinical Documentation Specialist (CCDS).
Utilization Management, Case Management, Quality Improvement, or Inpatient Coding experience.

Responsibilities

Reviews clinical records to identify gaps and collaborates with providers to improve quality.
Leads maintenance of clinical documentation accuracy and completeness.
Develops improvement strategies and training programs.
Monitors regulatory changes and leads audits and quality assurance.
Facilitates communication between clinical teams and coding specialists.
Reports findings and recommends corrective actions to uphold documentation standards.

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