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Clinical Documentation Integrity (Specialist)

Reviews inpatient and select outpatient medical records while patients are still in-house (concurrent review) for proper documentation. This review includes new admissions to the facility, as well as re-reviews every two to three days until the patients are discharged. Communicates with clinicians and physicians to ensure timely and accurate documentation and provides training and education as needed. Queries physicians on specificity of diagnoses and procedures performed in order to drive documentation to be ICD-10 compliant.

Required Qualifications

- Require a Bachelor’s degree (preferably BSN). Relevant acute care clinical work experience can substitute on a year-for-year basis for the required Bachelor’s degree; but, a minimum of an Associate’s degree in a relevant field is required.
- Require a minimum of three (3) years of experience in nursing or other relevant clinical area, coding, or utilization review/case management in an acute care facility.

Preferred Qualifications

- Prefer effective interpersonal skills in order to interact effectively with all levels of hospital personnel.
- Prefer demonstrated prioritization, organization and analytical skills.
- Prefer demonstrated effective written and verbal communications skills.
- Prefer demonstrated proficiency with Microsoft Office and related software packages.
- Prefer coding skills with experience in ICD-10-CM and working knowledge of the AHA Coding Clinic.
- Prefer Certified Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement Practitioner (CDIP) certification. - Prefer coding certification from the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC).

FL Registered Nurse License

Work days are Monday through Friday, no weekends.

Clinical Documentation Integrity (Specialist)

Sarasota, FL
Full Time

Published on 12/01/2021

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