Quality Documentation Specialist
Lee Health
Date: 1 day ago
City: Cape Coral, Florida
Salary:
$30.27
-
$40.86
per hour
Contract type: Full time
Location:Santa Barbara Professional Center -224 Santa Barbara BlvdCape Coral FL 33991
Department: CDI - Clinical Documentation
Work Type: Full Time
Shift: Shift 1/ to
Minimum to Midpoint Pay Rate:$30.27 - $40.86 / hour
Summary
Using a multidisciplinary team approach the Qualityl Documentation Specialist facilitates and obtains appropriate clinical documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. A diverse clinical background and in depth knowledge of pathophysiology is a must. With training, exhibits a detailed knowledge of clinical documentation requirements, DRG assignment, as well a firm understanding of coding guidelines. The CDIS educates members of the patient care team regarding clinical documentation guidelines, including attending physicians, allied health practitioners, and nursing. Reviews medical records concurrently on a daily basis to identify opportunities to improve the quality and completeness of clinical documentation. Facilitates modifications to clinical documentation when appropriate, through extensive concurrent interaction with physicians, mid-level providers, HIM staff, allied health professionals and nursing staff to support accurate, complete and timely documentation of clinical information in the electronic patient record. Coaches and educates physicians, mid-level providers, HIM staff, allied health professionals and nurses on a daily basis to improve capture of clinical severity for the level of service rendered to patients. This position will have a hybrid schedule after initial training period.
Requirements
Educational Requirements
Degree/Diploma ObtainedProgram of StudyRequired/
Preferredand/orBachelor'sRequired
Additional Requirements
Graduate of an accredited school of nursing. BSN or BS in a related healthcare field.
Experience Requirements
Minimum Years RequiredArea of ExperienceRequired/
Preferredand/or5 YearsClinical NursingRequired
State of Florida Licensure Requirements
LicensesRequired/
Preferredand/orRegistered Nurse LicenseRequired
Certifications/Registration Requirements
Certificates/RegistrationsRequired/
Additional Requirements
Preferredand/orCCDS (Certified Clinical Documentation Specialist)Preferred
Certification as a Documentation Improvement Specialist required within 2 years is
Required
US:FL:Cape Coral
Location:Santa Barbara Professional Center -224 Santa Barbara BlvdCape Coral FL 33991
Department: CDI - Clinical Documentation
Work Type: Full Time
Shift: Shift 1/ to
Minimum to Midpoint Pay Rate:$30.27 - $40.86 / hour
Required
US:FL:Cape Coral
Department: CDI - Clinical Documentation
Work Type: Full Time
Shift: Shift 1/ to
Minimum to Midpoint Pay Rate:$30.27 - $40.86 / hour
Summary
Using a multidisciplinary team approach the Qualityl Documentation Specialist facilitates and obtains appropriate clinical documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. A diverse clinical background and in depth knowledge of pathophysiology is a must. With training, exhibits a detailed knowledge of clinical documentation requirements, DRG assignment, as well a firm understanding of coding guidelines. The CDIS educates members of the patient care team regarding clinical documentation guidelines, including attending physicians, allied health practitioners, and nursing. Reviews medical records concurrently on a daily basis to identify opportunities to improve the quality and completeness of clinical documentation. Facilitates modifications to clinical documentation when appropriate, through extensive concurrent interaction with physicians, mid-level providers, HIM staff, allied health professionals and nursing staff to support accurate, complete and timely documentation of clinical information in the electronic patient record. Coaches and educates physicians, mid-level providers, HIM staff, allied health professionals and nurses on a daily basis to improve capture of clinical severity for the level of service rendered to patients. This position will have a hybrid schedule after initial training period.
Requirements
Educational Requirements
Degree/Diploma ObtainedProgram of StudyRequired/
Preferredand/orBachelor'sRequired
Additional Requirements
Graduate of an accredited school of nursing. BSN or BS in a related healthcare field.
Experience Requirements
Minimum Years RequiredArea of ExperienceRequired/
Preferredand/or5 YearsClinical NursingRequired
State of Florida Licensure Requirements
LicensesRequired/
Preferredand/orRegistered Nurse LicenseRequired
Certifications/Registration Requirements
Certificates/RegistrationsRequired/
Additional Requirements
Preferredand/orCCDS (Certified Clinical Documentation Specialist)Preferred
Certification as a Documentation Improvement Specialist required within 2 years is
Required
US:FL:Cape Coral
Location:Santa Barbara Professional Center -224 Santa Barbara BlvdCape Coral FL 33991
Department: CDI - Clinical Documentation
Work Type: Full Time
Shift: Shift 1/ to
Minimum to Midpoint Pay Rate:$30.27 - $40.86 / hour
Required
US:FL:Cape Coral
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