Overview

Responsible for facilitating improvement in inpatient clinical documentation through concurrent review of the medial record for accurate physician documentation of diagnoses based on clinical evidence present in the chart, application of official ICD-10-CM coding guidelines, and interaction with physicians and other clinicians. Identifies opportunities for improvement in clinical documentation and queries the physician for clarification to support more specific diagnoses. Collaborates with physicians and coders to obtain documentation that most accurately reflects patients severity of illness and risk of mortality. Educates all members of the patient care team on an ongoing basis.
Qualifications

Minimum Qualification & Education Requirements:: Graduate of an accredited school of nursing with current RN licensure in the State of Florida, or Advanced Medical Practitioner, or International Medical Diploma. Minimum 3 years of recent clinical experience in a hospital setting. Certified Clinical Documentation Specialist (CCDS) preferred. Utilization Management, Case Management, Quality Improvement or Inpatient Coding experience preferred. Motor Vehicle Designation:: Employees in this position: Will operate vehicles for an assigned business purpose as a non-frequent driver Licensure/Certification/Registration:: Registered Nurse (RN) in state of Fl required, or Advanced Medical Practitioner, or International Medical Diploma
Minimum Qualification & Education Requirements:: Graduate of an accredited school of nursing with current RN licensure in the State of Florida, or Advanced Medical Practitioner, or International Medical Diploma. Minimum 3 years of recent clinical experience in a hospital setting. Certified Clinical Documentation Specialist (CCDS) preferred. Utilization Management, Case Management, Quality Improvement or Inpatient Coding experience preferred. Motor Vehicle Designation:: Employees in this position: Will operate vehicles for an assigned business purpose as a non-frequent driver Licensure/Certification/Registration:: Registered Nurse (RN) in state of Fl required, or Advanced Medical Practitioner, or International Medical Diploma