Overview

Responsible for improving inpatient clinical documentation through concurrent review of the medical record to ensure accurate physician documentation based on clinical evidence and adherence to official ICD-10-CM coding guidelines. Identifies opportunities for documentation enhancement and queries physicians for clarification to support more specific and accurate diagnoses. Collaborates with physicians and coders to ensure documentation accurately reflects the patient’s severity of illness and risk of mortality. Provides ongoing education to all members of the patient care team to promote consistent, high-quality documentation practices.

 

Qualifications

Minimum Qualification & Education Requirements

Education & Credentials

• Graduate of an accredited school of nursing with current RN licensure in the State of Florida, OR
• Advanced Medical Practitioner, OR
• International Medical Diploma.

Experience

• Minimum 3 years of recent clinical experience in a hospital setting.
• Certified Clinical Documentation Specialist (CCDS) preferred.
• Experience in Utilization Management, Case Management, Quality Improvement, or Inpatient Coding preferred.

Motor Vehicle Operator Designation

Employees in this position may operate vehicles for assigned business purposes as a non-frequent driver.

Licensure / Certification / Registration

• Registered Nurse (RN) in the State of Florida required, OR
• Advanced Medical Practitioner, OR
• International Medical Diploma.