RN - Clinical Documentation Improvement Specialist

Baptist Health

3d

About The Position

The RN - Clinical Documentation Integrity Specialist facilitates the integrity, quality, and completeness of provider-based clinical documentation in the medical record. The Specialist extensively reviews medical records and works with physicians, clinical staff, and Coding staff to help ensure appropriate reimbursement for services rendered and complete, accurate clinical information for profiling and outcome reporting. Additional duties within the scope of the role may be assigned.

Requirements

• Degree in Nursing.
• At least 2 years of hospital clinical experience.
• Active RN license.
• Certified Clinical Documentation Specialist (CCDS) certification, or obtain it within 3 years of hire.
• Proficiency with Microsoft Word and Excel.
• Advanced computer skills for maintaining databases and spreadsheets and developing reporting tools, graphs, and control charts.
• Knowledge of accrediting and regulatory agency procedures and standard requirements.
• Excellent interpersonal skills for interacting with physicians and other professionals.
• Exceptional interpersonal communication, teaching and presentation, writing, analytical, and team-building skills.
• Knowledge of process improvement methodologies.
• Self-direction, strong motivation, problem-solving ability, and independent decision-making skills.
• Sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures.
• Extensive knowledge of ICD and reimbursement methodologies.

Nice To Haves

• Bachelor's degree in Nursing.
• Experience with DRGs.
• Regulatory survey coordination experience.
• Experience in project management, group facilitation, and leadership group presentations.

Responsibilities

• Review medical records to assess the quality, completeness, and integrity of clinical documentation.
• Interact with physicians, clinical staff, and Coding staff to support complete and accurate documentation.
• Help ensure reimbursement is appropriate for the level of services rendered.
• Support complete and accurate clinical information used in profiling and reporting outcomes.
• Perform additional duties within the scope of the role as assigned.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree