OverviewLeads in this position will lead the process in maintaining the accuracy and completeness of clinical documentation to support patient care and regulatory compliance. Reviews clinical records to identify gaps, collaborating with healthcare providers to enhance documentation quality, and developing improvement strategies and training programs. Monitors regulatory changes, leads audits and quality assurance activities, and facilitates communication between clinical teams and coding specialists. Reports findings and recommend corrective actions to uphold documentation standards and integrity.
ResponsibilitiesRN, Clinical Doc Int Spec Lead: - Reviews clinical records to identify gaps and collaborates with providers to improve quality.
- Leads maintenance of clinical documentation accuracy and completeness.
- Develops improvement strategies and training programs.
- Monitors regulatory changes and leads audits and quality assurance.
- Facilitates communication between clinical teams and coding specialists.
- Reports findings and recommends corrective actions to uphold documentation standards.
QualificationsRequired Education: Diploma. Associate's degree in nursing; Preferred Bachelor's Deegree
License/Certification/Registration: Florida Registered Nursing or Advanced Practitioner - Florida Driver license required
Preferred: Certified Clinical Documentation Specialist (CCDS). Utilization Management, Case Management, Quality Improvement or Inpatient Coding experience preferred.
• 5+ years' experience leading clinical documentation improvement programs
• Expertise in regulatory compliance and audit management
• Proven ability to develop training programs and improvement strategies
• Strong skills in cross-functional team leadership and communication
• Experience monitoring documentation quality and reporting outcomes
