Registered Nurse Clinical Documentation Specialist FT Days
Florida Hospital Flagler
At Florida Hospital Flagler, we’re deeply rooted in the community and strive to extend the healing ministry of Christ in everything we do. Our recently constructed, state-of-the-art hospital in Palm Coast, Florida is equipped with the latest technology, specially trained experts, and advanced care centers.
Florida Hospital Flagler is owned and operated by Adventist Health System, a faith-based health care organization. Through our Christian mission of hope, health and healing, we strive to promote wellness of mind, body and spirit. At Florida Hospital Flagler, providing the best possible care to our community requires hiring the best possible care providers.
• The Joint Commission has recognized Florida Hospital Flagler as a Top Performer on Key Quality Measures.
• Accredited Orthopedic Center of Excellence from The Joint Commission. The Joint Commission has also recognized Florida Hospital Flagler as a Top Performer on Key Quality Measures
• Recognized by the American Heart Association as a Platinum-Level Fit-Friendly Worksite
• “A” rating on patient safety from The Leapfrog Group based on our exemplary services, processes and structures.
• Designated Breast Imaging Center of Excellence according to the American College of Radiology (ACR).
• Commission on Cancer Accreditation recognizing commitment to provide exceptional care to patients
• Named a Gallup Great Workplace Award winner for fifth year in a row.
We offer career opportunities in a variety of setting from physician office practices, to acute care, home care and hospice. If Florida Hospital Flagler sounds like your next career destination, we encourage you to apply today.
- 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.
- A knowledge base of working DRG assignment and Medicare and Medicaid regulations as related to inpatient coding.