Clinical Documentation Specialist Full Time Days
Job description
Step into Florida – The most sizzling state in the nation, where there are high tides and good vibes. Grow within an organization of support and superior patient care within Tenet Healthcare Hospitals. Our CDI program offers relocation assistance and sign on bonus to selected CDI candidates.
Primary assignment location: Good Samaritan Medical Center in Palm Beach Gardens, Florida
Position Summary: Under general supervision of the Clinical Documentation Integrity Program Manager, the Clinical Documentation Specialist II is responsible for improving overall quality and completeness of clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physician, case management, nursing staff, other patient caregivers and coding staff. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician outcomes.
POSITION ACCOUNTABILITIES AND PERFORMANCE CRITERIA
- Initiates and performs concurrent documentation review of selected inpatient records to clarify conditions/diagnosis and procedures where inadequate or conflicting documentation is suspected. Meets or exceeds defined performance standards for chart reviews and queries.
- Improves coding specificity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay. This includes capturing complications/co-morbidities during the patient’s stay. This is achieved via queries, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal. Serves as a resource for physicians to help link ICD-10-CM coding guidelines and medical terminology to improve accuracy of final code assignment.
- Follows guidelines for coding and documentation to ensure physician and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned based on documentation. Participates in educational programs and in-services in order to maintain and exceed excellence in coding skills.
Qualifications
EducationRequired: Graduate of a foreign medical school or education recognized by the State of Florida, as qualification for licensed Registered Nurse or LPN,
Preferred: MBA, MPH, MHA or MSN
Required: Minimum of 2 years clinical or inpatient experience in an acute care setting required; 5 years strongly preferred.
Required Certifications/Licensure/Registration- Must be either: licensed in the State of Florida as a Registered Nurse, LPN, Physician Assistant or APRN licensed in the State of Florida or a graduate of a foreign medical school (with ECFMG Certification preferred but not required)
- Certified in one of the following within 2 years of hire into the position:
- Certification in clinical documentation improvement through ACDIS or AHIMA (CCDS or CDIP) strongly desired.
- Certified in coding (CCS) preferred.
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Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.
Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
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