Clinical Documentation Improvement Specialist
Florida Hospital Carrollwood
Will promote from within for specialized OR positions, offering training for lead, OR business management, and first assist position
You will be responsible for:
Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient’s severity of illness and risk of mortality utilizing appropriate query tools to capture needed documentation. Conducts follow-up on unanswered queries, as needed, to obtain a response to open queries in a promptly manner.
· Reviews clinical issues with coding staff as needed to ensure appropriate coding (i.e. APDRG, HCC, MSDRG). Serves as a resource to physicians and other members of the healthcare team, regarding issues related to the appropriateness of inpatient DRG assignment.
· Serves as the ambassador of the CDS program for the healthcare team.
· Assists with special projects as needed & performs other duties as assigned.
· Conducts concurrent reviews and post-discharge reviews on all selected admissions for opportunities to clarify documentation in the medical record for an accurate reflection of severity of illness.
· Possesses in-depth knowledge of DRG payer issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures.
· Ensures the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes, including but not limited to POA – Present on Admission status, PSI - Patient Safety Indicators, Mortality (Severity of Illness/Risk of Mortality) and Core Measures (i.e. Sepsis, Stroke)
· Tracks responses to clinical documentation and trends data in collaboration with other departments.
KNOWLEDGE AND SKILLS REQUIRED:
· Knowledge of care delivery documentation systems.
· Knowledge of age specific needs and the elements of disease processes and related procedures.
· Strong broad-based clinical knowledge and understanding of pathology/physiology.
· Excellent written and verbal communication skills and critical thinking skills.
· Assertive personality traits to facilitate ongoing physician communication.
· Ability to work independently in a time-oriented environment.
· Computer literacy and familiarity with the operation of basic office equipment.
· Ability to stand and walk in the performance of job responsibilities
EDUCATION AND EXPERIENCE REQUIRED:
· Graduate of an accredited School of Nursing
· Minimum of two (2) years recent Clinical Documentation Improvement Specialist experience in an
acute care setting.
EDUCATION AND EXPERIENCE PREFERRED
· Bachelor degree or Higher in Nursing
LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:
· Licensed as an RN in the state of Florida.
· Certified Coding Specialist (CCS), Certified Documentation Improvement Practitioner (CDIP), or Certified Clinical Documentation Specialist (CCDS) or willing to acquire certification within 1 year of hire.