Schedule:

Full time

Shift:

Day (United States of America)

Address:

900 HOPE WAY

City:

ALTAMONTE SPRINGS

State:

Florida

Postal Code:

32714

Job Description:

• Recognizes opportunities for documentation improvement using strong critical-thinking skills and formulates clinically credible clarifications for inpatients.
• Transcribes documentation clarifications as appropriate to ensure documentation compliance.
• 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 health information management staff to resolve discrepancies with diagnostic assignments and other coding issues.
• Completes well-timed follow-up case reviews on all cases, prioritizing those with clinical documentation clarifications.
• Participates in department meetings, providing feedback on outstanding issues and presenting educational opportunities.
• Assumes personal responsibility for professional growth, development, and continuing education to maintain a high level of proficiency.
• Assists in new hire orientation through precepting and mentoring.
• Maintains regional productivity standards and demonstrates competence on compliance audit scores.
• Maintains a 97% physician response rate to all valid clarifications.
• Annual participation in Advanced Practice call. Maintains CCDS credentialing.
• Other duties as assigned.
• Reviews concurrent medical records for documentation compliance, including completeness, accuracy and quality.
• Inputs data accurately and concisely into assigned software, resulting in accurate metrics obtained through the reconciliation process.

Knowledge, Skills, and Abilities:
• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations.
• 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.
• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist.
• Dependable, self-motivated, and pleasant.
• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills.
• Knowledge of pathophysiology, disease processes and treatments.
• Strong ability to organize/triage work and manage multiple priorities at once. [Required]
• Knowledge of clinical documentation requirements that identify clinical conditions or procedures.
• Coding background.
• Knowledge of quality guidelines. [Preferred]
Education:
• Bachelor's of Nursing [Required]
• Master's [Preferred]
Field of Study:
• in healthcare related field

Work Experience:
• 5+ years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience. [Required]
• 3+ years of Clinical Documentation Specialist experience [Required]

Additional Information:
• An equivalent combination of education and relevant work experience may be considered in lieu of the stated degree requirement:- BSN and 3+ years of Clinical Documentation Specialist experience OR - 4+ years of Clinical Documentation Specialist experience OR -Less than 2 years of Clinical Documentation Integrity experience and 10 years of acute care nursing experience.

Licenses and Certifications:
• Registered Nurse (RN) [Required] OR
• Adult Acute Care Nurse Practitioner (ACNPC) [Required] OR
• Physician Assistant (PA) [Required] OR
• Certified Clinical Documentation Specialist (CCDS) [Required] OR
• Certified Documentation Improvement Practitioner (CDIP) [Required]
• Certified Coding Specialist (CCS) [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