RN - Clinical Documentation Improvement Specialist

Baptist Health

2d • Onsite

About The Position

The RN - Clinical Documentation Integrity Specialist shall be responsible to facilitate integrity in the overall quality and completeness of provider-based clinical documentation in the medical record. The Specialist will assess clinical documentation through extensive review of the medical record, interact with Physicians, clinical staff, and Coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and that the clinical information utilized in profiling and reporting outcomes is complete and accurate. This position may have additional duties assigned that are within scope of the role.

Requirements

• Active RN license required.
• Minimum 2 years hospital clinical experience required.
• Proficient in use of Microsoft Word and Excel programs.
• Must possess advanced computer skills to maintain databases, spreadsheets and develop reporting tools/graphs/control charts.
• Must have knowledge of accrediting and regulatory agencies procedures and standard requirements.
• Must have excellent interpersonal skills to interact with physicians and other professionals.
• Must have exceptional interpersonal communications, teaching/presentation and writing skills, analytical and strong team building skills.
• Must have knowledge of process improvement methodologies.
• Must be self-directed and highly motivated with problem solving abilities.
• Must possess independent decision-making skills.
• Exhibits a 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 preferred.
• Experience with DRGs preferred.
• Certified Clinical Documentation Specialist (CCDS) required or obtained within 3 years of hire.
• Regulatory survey coordination experience strongly preferred.
• Experience in project management, group facilitation and leadership group presentations preferred.

Responsibilities

• Facilitate integrity in the overall quality and completeness of provider-based clinical documentation in the medical record.
• Assess clinical documentation through extensive review of the medical record.
• Interact with Physicians, clinical staff, and Coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients.
• Ensure that the clinical information utilized in profiling and reporting outcomes is complete and accurate.

What This Job Offers

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