Clinical Document Integrity Specialist - RN | Clinical Documentation Integrity |
UF Health, Jacksonville, Florida, United States, 32290
Overview
The Clinical Documentation Specialist conducts medical record reviews and identifies documentation needs within the medical record. The position also communicates, either verbally or in writing, with health care providers to address those needs in the medical record. Responsibilities
Clinical Documentation Specialist – Key Responsibilities Facilitates and obtains
appropriate physician documentation for all clinical conditions and procedures to accurately reflect the patient’s
severity of illness ,
risk of mortality , and
complexity of care . Queries physicians
regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional details within the health record as needed. Completes initial reviews
of patient records within
24–48 hours of admission
for an assigned patient population to: Evaluate documentation to assign the
principal diagnosis ,
pertinent secondary diagnoses , and
procedures
for accurate
DRG assignment ,
risk of mortality , and
severity of illness . Initiate and maintain a
review worksheet
for each case. Conducts follow-up reviews
every
2–3 days
to support and confirm a
working or final DRG assignment
upon patient discharge, as necessary. Utilizes the
Concurrent Query Structured Note in Allscripts
to issue physician queries. Processes documentation queries
requested by the
coding department . Educates physicians and key healthcare providers
on clinical documentation improvement (CDI) principles and the importance of accurate and complete documentation in the health record. Collaborates
with case managers, nursing staff, and other ancillary team members to communicate and resolve documentation issues or physician queries
prior to patient discharge
when possible. Assists in preparing and presenting
clinical documentation
monitoring and trending reports
for review with physicians and hospital leadership. Educates patient care team members
regarding specific documentation requirements,
reporting and reimbursement issues , and findings identified through daily and retrospective reviews or aggregate data analysis. Performs other duties
as assigned by the department. Qualifications
Graduate Accredited School of Nursing Min Experience Type of Experience 5 to 7 years Acute Nursing Care in Hospital Environment Preferences: Clinical documentation improvement and or ICD-10 coding experience. Additional Information: Licensing Requirements Certificates/Licenses/Registration Active FL RN License CCDS – Certified Clinical Document Preferences: Additional Information: CCDS required within 4 years of hire or transfer date.
#J-18808-Ljbffr
The Clinical Documentation Specialist conducts medical record reviews and identifies documentation needs within the medical record. The position also communicates, either verbally or in writing, with health care providers to address those needs in the medical record. Responsibilities
Clinical Documentation Specialist – Key Responsibilities Facilitates and obtains
appropriate physician documentation for all clinical conditions and procedures to accurately reflect the patient’s
severity of illness ,
risk of mortality , and
complexity of care . Queries physicians
regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional details within the health record as needed. Completes initial reviews
of patient records within
24–48 hours of admission
for an assigned patient population to: Evaluate documentation to assign the
principal diagnosis ,
pertinent secondary diagnoses , and
procedures
for accurate
DRG assignment ,
risk of mortality , and
severity of illness . Initiate and maintain a
review worksheet
for each case. Conducts follow-up reviews
every
2–3 days
to support and confirm a
working or final DRG assignment
upon patient discharge, as necessary. Utilizes the
Concurrent Query Structured Note in Allscripts
to issue physician queries. Processes documentation queries
requested by the
coding department . Educates physicians and key healthcare providers
on clinical documentation improvement (CDI) principles and the importance of accurate and complete documentation in the health record. Collaborates
with case managers, nursing staff, and other ancillary team members to communicate and resolve documentation issues or physician queries
prior to patient discharge
when possible. Assists in preparing and presenting
clinical documentation
monitoring and trending reports
for review with physicians and hospital leadership. Educates patient care team members
regarding specific documentation requirements,
reporting and reimbursement issues , and findings identified through daily and retrospective reviews or aggregate data analysis. Performs other duties
as assigned by the department. Qualifications
Graduate Accredited School of Nursing Min Experience Type of Experience 5 to 7 years Acute Nursing Care in Hospital Environment Preferences: Clinical documentation improvement and or ICD-10 coding experience. Additional Information: Licensing Requirements Certificates/Licenses/Registration Active FL RN License CCDS – Certified Clinical Document Preferences: Additional Information: CCDS required within 4 years of hire or transfer date.
#J-18808-Ljbffr