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Quality Documentation Specialist

Location: 12901 McGregor Blvd, Fort Myers, FL
Department: CDI - Clinical Documentation
Categories: HIM / CDI
Type: Full-Time
Shift: 8:00 AM-4:30 PM
Schedule: Days

Description:

Using a multidisciplinary team approach the Quality 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.

Requirements:

Educational Requirements

Degree/Diploma ObtainedProgram of StudyRequired/
Preferred
and/or
Bachelor'sRequired

Additional Requirements

Graduate of an accredited school of nursing. BSN or BS in a related healthcare field, or able to obtain within two years of hire.

Experience Requirements

Minimum Years RequiredArea of ExperienceRequired/
Preferred
and/or
5 YearsClinical NursingRequired

State of Florida Licensure Requirements

LicensesRequired/
Preferred
and/or
Registered Nurse LicenseRequired

Certifications/Registration Requirements

Certificates/RegistrationsRequired/
Preferred
and/or
CCDS (Certified Clinical Documentation Specialist)Preferred

Additional Requirements

Certification as a Documentation Improvement Specialist required within 2 years is required