Reviews concurrent inpatient medical records to identify opportunities for documentation improvement and ensure documentation compliance.
Works collaboratively with physicians, nursing staff, allied health practitioners, and health information management staff to clarify diagnoses, improve documentation quality, and resolve coding-related discrepancies.
Participates in follow-up case reviews, department meetings, education efforts, orientation support, and ongoing professional development.
Maintains productivity and compliance standards while accurately entering review data into assigned systems.
Bachelor of Nursing required; master's degree preferred.
5+ years of acute care nursing experience, including medical/surgical, intensive care, post-acute care, or emergency department experience.
3+ years of Clinical Documentation Specialist experience.
Active licensure or certification as one of the following is required: Registered Nurse (RN), Adult Acute Care Nurse Practitioner (ACNPC), Physician Assistant (PA), Certified Clinical Documentation Specialist (CCDS), or Certified Documentation Improvement Practitioner (CDIP).
Certified Coding Specialist (CCS) preferred.
Strong critical-thinking, problem-solving, communication, organization, and physician-relations skills.
Knowledge of clinical documentation requirements, disease processes, treatments, and quality guidelines preferred.
Benefits from day one, including medical, dental, vision, life, and disability insurance.
Paid time off from day one.
403(b) retirement plan.
4 weeks of 100% paid parental leave.
Career development support.
Whole person well-being resources.
Mental health resources and support.
Pet benefits.
Location
Florida, US
Employment Type
Full-time
Experience Level
Senior
Salary Range
$66,171 - $123,073
Remote work allowed
No
Posted
1 month ago