Schedule: Full time
Shift: Day (United States of America)
Address: 301 MEMORIAL MEDICAL PKWY
City: DAYTONA BEACH
State: Florida
Postal Code: 32117
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.
- 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.
- Performs 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. [Required]
- 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]
- 2+ clinical documentation specialist experience [Required]
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) [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
