Ascension

Registered Nurse Clinical Documentation Specialist

Ascension$84K — $118K *
Healthcare
5 - 7 years of experience
Job Overview by Ladders

Qualifications

  • Registered Nurse licensed by the Florida Board of Nursing required
  • Diploma from an accredited nursing school required
  • 5+ years of Cardiac/ICU experience preferred
  • Experience in Clinical Documentation Improvement (CDI) preferred
  • CCDS certification preferred

Responsibilities

  • Complete admission reviews and assign a working Diagnosis Related Group
  • Ensure accurate entry of the working DRG into the Clinical Documentation Improvement database
  • Engage with physicians and mid-level providers to enhance medical record details
  • Collaborate with healthcare professionals to reflect accurate patient severity and services in documentation
  • Maintain valid records of CDI review activities and outcomes

Benefits

  • Full-time day shift schedule
  • Opportunity to work remotely
  • Engagement in an impactful healthcare role
  • Collaboration with a team of healthcare professionals
  • Potential for professional development through certifications like CCDS
Full Job Description
Your future role at a glance

Location: Pensacola, FL | Remote

Facility: Ascension Sacred Heart

Department: Clinical Integrity Documentation

Schedule: Day Shift | Full-Time

Salary Range: $84,060.91 - $118,668.99 per year

How you'll make an impact in this role

  • Complete admission reviews and assign a working Diagnosis Related Group.
  • Ensure the working DRG and other information are entered in the Clinical Documentation Improvement database.
  • Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.
  • Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge.
  • Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.

What minimum requirements you'll need

Licensure / Certification / Registration:

  • Registered Nurse credentialed from the Florida Board of Nursing obtained prior to hire date or job
    transfer date required. Licensed as a Registered Nurse in Florida required. Credentialed from State Board of Nursing
    or current home state license for multi-state license recognition "Compact State" obtained prior to
    hire date or job transfer date required.


Education:

  • Diploma from an accredited school/college of nursing OR Required professional licensure at time of
    hire.

What additional preferences we're seeking

  • 5+ years Cardiac/ICU experience
  • CDI experience preferred
  • CCDS certification preferred


Responsibilities

  • Complete admission reviews and assign a working Diagnosis Related Group.
  • Ensure the working DRG and other information are entered in the Clinical Documentation Improvement database.
  • Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.
  • Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge.
  • Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.


Qualifications

Licensure / Certification / Registration:

  • Registered Nurse credentialed from the Florida Board of Nursing obtained prior to hire date or job
    transfer date required. Licensed as a Registered Nurse in Florida required. Credentialed from State Board of Nursing
    or current home state license for multi-state license recognition "Compact State" obtained prior to
    hire date or job transfer date required.


Education:

  • Diploma from an accredited school/college of nursing OR Required professional licensure at time of
    hire.

About Ascension

Ascension is a healthcare company that provides a range of services, including hospital care, primary care, and specialty care. The company operates more than 150 hospitals and 50 senior living facilities across the United States. Ascension also offers health insurance and other healthcare-related services. The company was founded in 1999 and is headquartered in St. Louis, Missouri.
Learn more about Ascension
Size
165,000 employees
Industry
Founded
1999

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