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.
This role educates members of the patient care team on documentation guidelines and works closely with physicians, nursing, and HIM coders to ensure documentation integrity, compliance, and accurate record review. The position also supports CDI operations through concurrent case review, clarification workflows, data entry, and collaboration on DRG and coding issues.
Additional responsibilities include serving as a subject matter expert, supporting physician onboarding, assisting with audits, mentoring new staff, and maintaining high performance standards in physician response and compliance audit scores.
Required experience
- 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
Education
- Associate degree in nursing or a health-related field
Licensure and certifications
- One of the following: RN, PA, CRNP, APRN, MD, DO, or ECFMG eligibility
- Certified Clinical Documentation Specialist (CCDS)
Skills and qualifications
- Excellent verbal and written communication skills
- Strong physician relations and interpersonal skills
- Ability to organize, prioritize, and manage multiple workstreams
- Excellent computer and keyboarding skills
- Ability to use multiple software systems simultaneously
- Strong critical thinking, problem-solving, and deductive reasoning skills
- Knowledge of pathophysiology, disease processes, and treatments
- Preferred: clinical documentation knowledge, coding background, and quality guideline experience
Benefits and 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