Registered Nurse Clinical Document Specialist FT Days
Florida Hospital New Smyrna
Since 1954, Florida Hospital New Smyrna (formerly Bert Fish Medical Center) has served as the community hospital for Southeast Volusia County. Our more than 700 employees use an impressive array of technology and years of knowledge to provide exceptional care for every patient – every day. We offer a wide range of services, including a surgery program, radiology, an oncology center, cardiovascular services, a wound care center, outpatient diagnostic services, and one of the busiest emergency departments of any hospital our size.Qualifications
- The Clinical Documentation Specialist will be responsible for conducting clinically based current and retrospective reviews of inpatient medical records to evaluate the clinical documentation of clinical services.
- Identify and clarify missing, conflicting, or nonspecific physician documentation related to diagnoses and procedures.
- Support accurate diagnostic and procedural coding, DRG assignment, severity of illness, and expected risk of mortality, leading to appropriate reimbursement.
- Proactively solicits clarification from physicians when further specificity is needed in the documentation, and consults with attending physician when conflicting information appears in the medical record.
- Completes initial reviews for a specified patient population to a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness; and b) initiate a review worksheet. Conducts follow-up reviews of patients to support and assign a working or final DRG assignment upon patient discharge, as necessary. Demonstrates clinical knowledge skills/abilities for the patient population served.
- Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
- Communicates with the coding professionals as needed by phone or email to ensure accuracy of diagnosis and procedural data for appropriate DRG assignment.
- Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to identify potential opportunities for documentation improvement or clarification.
- Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health care record. The education is based on Centers for Medicare and Medicaid Services (CMS) documentation guidelines, current coding guidelines, and AHA Coding Clinics.
- Demonstrates knowledgeable working expertise in the use of CDMP Software program, Cerner, Microsoft Word, Microsoft PowerPoint, Microsoft Excel program, and the Internet.
- Tracks responses to CDMP; trends/tracks compliance. Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
- Responsible for adhering to the hospital Corporate Compliance plan, Policies and Procedures and to the rules and regulations of all local, state and Federal agencies and to the standards of all accrediting bodies.
- Graduate of an approved school of nursing.
- Bachelor’s Degree in Nursing or other field of study.
- Current registration and license with state board of examiners and holds a Florida RN license.
- Demonstrates the ability to apply to a high degree abstract reasoning, technical skills and abilities to the patient care setting and ancillary departments.
- A minimum of five years of nursing experience within the acute care setting and strong verbal and written communication skills.
- Clinical knowledge of payment systems and methodologies, ICD-9 and ICD-10 coding concepts and guidelines, coding guidelines, AHA coding clinics, and healthcare regulatory compliance.