Schedule: Full time
Shift: Day (United States of America)
Address: 1500 SW 1ST AVE
City: OCALA
State: Florida
Postal Code: 34471
Job Description: - Educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, and nursing staff.
- Communicates effectively with physicians and other healthcare providers to ensure appropriate, accurate, and complete clinical documentation.
- Collaborates with staff to resolve discrepancies with assignments and coding issues.
- Conducts well-timed follow-up case reviews on all concurrent cases, prioritizing those with clinical documentation clarifications.
- Participates in department meetings, providing feedback on outstanding issues and presenting educational opportunities.
- Maintains a 95% physician response rate to all valid clarifications.
- Reviews concurrent medical records for compliance, including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), and quality.
- Completes accurate and timely record reviews to ensure the integrity of documentation compliance.
- Inputs data accurately into CDI Software, resulting in precise metrics obtained through the reconciliation process.
- Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients, presenting opportunities for improved documentation compliance to clinical team members.
- Transcribes documentation clarifications as appropriate to ensure documentation compliance.
- Other duties as assigned.
Knowledge, Skills, and Abilities: - Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations [Required]
- Able to organize and present information clearly and concisely; excellent computer and keyboarding skills; ability to use multiple software programs simultaneously; high degree of prioritization skills [Required]
- Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist [Required]
- Dependable, self-motivated and pleasant [Required]
- Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills [Required]
- Knowledge of pathophysiology, disease processes and treatments [Required]
- Strong ability to organize/triage work and manage multiple priorities at once [Required]
- Knowledge of clinical documentation requirements that identify clinical conditions or procedures [Preferred]
- Coding background [Preferred]
- Knowledge of quality guidelines [Preferred]
Education: Field of Study: - in nursing or health related field
Work Experience: - 4+ acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience [Required]
- Clinical Documentation Specialist experience [Preferred]
Additional Information: - Candidate may be an unlicensed physician who graduated from a medical school listed in the World Directory of Medical Schools AND meets eligibility requirements to apply for the ECFMG Certification.
Licenses and Certifications: - Registered Nurse (RN) [Required] OR Physician Assistant (PA) [Required] OR Certified Registered Nurse Practitioner (CRNP) [Required] OR Advanced Practice Registered Nurse (APRN) [Required] OR Medical Doctor (MD) [Required] OR Doctor of Osteopathic Medicine (DO) [Required] OR Educational Commission for Foreign Medical Graduates (ECFMG) [Required]
- Certified Clinical Documentation Specialist (CCDS) [Preferred]
Physical Requirements: (Please click the link below to view work requirements)
Physical Requirements - https://tinyurl.com/23km2677
Pay Range:$66,170.74 - $123,073.07
