CDIS, RN | CDIS | FT Days

UF Health; Lady Lake (FL); On-site; USD 70,000 - 90,000; Full time

Job summary

UF Health Spanish Plains Hospital is seeking a Clinical Documentation Specialist to join our team. This role involves reviewing clinical records for accuracy and ensuring quality patient care documentation. Candidates should have a Bachelor's Degree or Nursing Diploma, along with a Florida Registered Nursing License and substantial acute care experience. This position plays a crucial role in maintaining healthcare quality standards and supporting our clinical teams.

Qualifications

• Florida Registered Nursing License required.
• 5 years of ICU, critical care, med-surg, or other acute care experience.
• Must read, write, speak, and understand English.

Responsibilities

• Review clinical records for accuracy related to MS-DRG or APR DRG.
• Interact with physicians, nurses, coders, and other clinical staff.
• Ensure clinical records accurately reflect the level of services rendered.

Skills

Interpersonal Skills

Attention to Detail

Communication

Critical Thinking

Education

Bachelor's Degree (Preferred)

Diploma/Associates Degree in Nursing

Job description

Overview

UF Health Spanish Plains Hospital, formerly known as The Villages Regional Hospital and acquired by University of Florida Health in January 2020, has been serving residents of The Villages as well as patients in Lake, Sumter, and Marion counties since 2002. At UF Health The Villages Hospital, we are committed to providing the community with leading-edge patient care, clinical training, and research programs. Our teams of physicians and clinical staff work together to offer specialty services, advanced technology, and clinical studies – bringing world-class health care closer to you and your loved ones.

We are part of UF Health Central Florida, a not-for-profit health care system and the largest, most comprehensive provider of health care services in the region. UF Health Central Florida provides inpatient acute hospital services at UF Health Spanish Plains Hospital and UF Health Leesburg Hospital, inpatient rehabilitation services at UF Health Rehab Hospital – The Villages, and diagnostic laboratory services at several locations. We pride ourselves on providing progressive, innovative technology and building strong relationships with patients, families, physicians, and residents of the communities we serve.

Responsibilities

The Clinical Documentation Specialist (CDS) reviews the clinical record for accuracy related to the MS-DRG or the APR DRG, co-morbidities, and complications. They have extensive interaction with physicians, nurses, coders, and other clinical staff to ensure the clinical record accurately reflects the level of services rendered.

Qualifications

Education:

- Bachelor's Degree (Preferred)

- Diploma/Associates Degree in Nursing

Licensure/Certification/Registration:

- Florida Registered Nursing License

- Passing score on Clinical Competency Exam

Special Skills/Qualifications/Additional Training/Experience Required:

- Must be able to read, write, speak, and understand English

- 5 years of ICU, critical care, med-surg, or other acute care experience