About The Position

The RN, Clinical Documentation Integrity Specialist ensures the accuracy, completeness, and regulatory compliance of clinical documentation. The role collaborates with healthcare providers to enhance documentation quality and analyzes clinical records to identify discrepancies and implement improvements. The specialist monitors adherence to documentation policies, educates clinical staff on best practices, and supports audits and quality assurance activities. The role reports findings and recommends corrective actions to management to support continuous improvement.

Requirements

  • Graduate of an accredited school of nursing.
  • At least 3 years of experience in clinical documentation improvement.
  • Knowledge of healthcare regulations and documentation standards.
  • Experience conducting audits and quality assurance activities.
  • Strong collaboration skills with clinical providers and coding teams.
  • Ability to develop and deliver staff education and training.
  • Active State of Florida nurse license.

Responsibilities

  • Ensure the accuracy, completeness, and regulatory compliance of clinical documentation.
  • Collaborate with healthcare providers to enhance documentation quality.
  • Analyze clinical records to identify discrepancies and implement improvements.
  • Monitor adherence to documentation policies and educate clinical staff on best practices.
  • Support audits and quality assurance activities.
  • Report findings and recommend corrective actions to management.
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