Responsible for facilitating and obtaining quality physician documentation for clinical conditions and procedures to support severity of illness, risk of mortality, and complexity of patient care. Educates members of the patient care team on documentation guidelines, collaborates with physicians, nursing, and HIM coders, and ensures quality documentation and regulatory compliance.
Key duties include:
- Conduct concurrent case reviews and follow up on documentation clarifications
- Educate staff on documentation regulations and Medicare updates
- Collaborate with HIM staff to resolve DRG and coding discrepancies
- Review medical records for completeness, accuracy, and compliance
- Document and track CDI metrics in software systems
- Develop clinically credible clarifications and severity worksheets
- Serve as a subject matter expert and liaison for new physician onboarding
- Assist with orientation, mentoring, and auditing activities
Requirements & Qualifications
- Associate degree in nursing or a health-related field
- 4+ years of acute care nursing experience in medical/surgical, intensive care, post-acute care, or emergency department settings
- 2+ years of clinical documentation specialist experience
- Current or eligible credentials/licensure: RN, PA, CRNP, APRN, MD, DO, or ECFMG
- Certified Clinical Documentation Specialist (CCDS) required
- Strong verbal and written communication skills
- Excellent physician relations and interpersonal skills
- Ability to manage multiple priorities and use multiple software systems
- Knowledge of pathophysiology, disease processes, and treatments
- Critical thinking, problem-solving, and deductive reasoning skills
- Coding background and quality guideline knowledge preferred
Benefits & Perks
- Medical, dental, and vision insurance
- Life insurance and disability insurance
- Paid time off from day one
- 403(b) retirement plan
- 4 weeks of 100% paid parental leave
- Career development opportunities
- Whole person well-being resources
- Mental health resources and support
- Pet benefits
- Up to $7,500 sign-on bonus
Location
Florida, US
Employment Type
Full-time
Experience Level
Senior
Salary Range
$72,787 - $135,385
Remote work allowed
Yes
Posted
4 weeks ago