Clinical Document Improvement Specialist - RN CDIS Full Time Day

Overview

FTE: 1.0

Mon-Fri 8:00 am to 5:00 pm

Responsible for facilitating improvement in inpatient clinical documentation through concurrent review of the medical record to ensure accurate physician documentation of diagnoses based on clinical evidence, appropriate application of ICD-10-CM coding guidelines, and collaboration with physicians and other clinicians. Identifies opportunities to enhance clinical documentation and queries physicians for clarification to support more specific, accurate diagnoses. Works closely with physicians and coders to obtain documentation that best reflects the patient's severity of illness and risk of mortality. Provides ongoing education to all members of the patient care team.

Qualifications

Minimum Qualifications & Education

Graduate of an accredited school of nursing with current RN licensure in Florida,

OR Advanced Medical Practitioner,

OR International Medical Diploma.

Minimum 3 years of recent clinical experience in a hospital setting.

Preferred:

Certified Clinical Documentation Specialist (CCDS).

Experience in Utilization Management, Case Management, Quality Improvement, or Inpatient Coding. Motor Vehicle Designation

This position requires operation of vehicles for business purposes as a non-frequent driver. Licensure/Certification/Registration

RN licensure in the State of Florida required,

OR Advanced Medical Practitioner,

OR International Medical Diploma.

Option 3: Concise Summary

Requires graduation from an accredited nursing program with Florida RN licensure, an Advanced Medical Practitioner credential, or an International Medical Diploma. Must have at least three years of recent hospital clinical experience. CCDS certification and experience in Utilization Management, Case Management, Quality Improvement, or Inpatient Coding are preferred. Position is designated as a non-frequent driver for business-related vehicle use.