Clinical Document Specialist III

Leoforce; Florida; Hybrid; USD 110,000 - 130,000; Full time

Benefits offered by this job

Hybrid work environment

Relocation assistance

Medical benefits

Job summary

Leoforce is seeking a Clinical Document Specialist III to lead our CDI team and elevate the accuracy of patient records across emergency, surgical, ICU, and post-acute care.

You will implement strategies to improve documentation quality, provide training to the CDI team, and ensure CMS and CCDS guidelines are met, collaborating with nursing and physician staff in a hybrid work environment.

Qualifications

• Bachelor's degree or higher required; an advanced degree is a plus.
• Minimum 5 years of acute care nursing experience in medical/surgical, ICU, post-acute, or ED.
• At least 2 years as a Clinical Documentation Specialist.
• RN/NP/PA licensure.
• Experience leading a CDI team in a healthcare setting.
• Strong knowledge of CMS and CCDS guidelines.
• Excellent communication and collaboration with clinicians and admins.
• CDI certification (CCDI) desirable.

Responsibilities

• Lead the CDI team to ensure high-quality clinical documentation.
• Develop and implement strategies to improve accuracy, completeness, and consistency.
• Provide guidance and training on documentation standards and best practices.
• Collaborate with medical, surgical, ICU, and post-acute units to align practices.
• Conduct regular audits and provide feedback to providers and team.
• Monitor CDI quality metrics and drive corrective actions.
• Stay updated on CMS and CCDS guidelines for compliance.
• Foster a culture of continuous improvement and efficiency.

Skills

Nursing leadership

CMS knowledge

Team management

Communication

Quality improvement

CDI expertise

Education

Bachelor's degree or higher

Advanced degree (preferred)

Tools

Healthcare information systems

Clinical documentation software

Job description

Experience: Mid Level

Salary: $110,000 - $130,000 per year

Job Details

We are seeking an enthusiastic and experienced Clinical Document Specialist III to join our dynamic healthcare team. This role is critical in leading the Clinical Documentation Improvement (CDI) team to ensure the accuracy, integrity, and quality of patient records. The successful candidate will have a strong understanding of various medical departments, including emergency, surgical, intensive care, and post-acute care units. The role demands a professional with a proven track record in healthcare quality management, specifically in the areas of CMS and CCDS.

Responsibilities:

• 1. Lead the Clinical Documentation Improvement (CDI) team to ensure high-quality documentation of clinical care.
• 2. Develop and implement strategies to enhance the accuracy, completeness, and consistency of clinical documentation.
• 3. Provide guidance and training to the CDI team on clinical documentation standards and best practices.
• 4. Collaborate with medical, surgical, intensive care, and post-acute care units to ensure alignment of documentation practices.
• 5. Conduct regular audits of clinical documentation and provide feedback to the CDI team and healthcare providers.
• 6. Monitor and report on CDI quality metrics, identifying areas for improvement and implementing corrective actions.
• 7. Stay updated on CMS and CCDS guidelines and ensure compliance within the organization.
• 8. Foster a culture of continuous improvement, encouraging innovation and efficiency within the CDI team.

Qualifications:

• 1. A bachelor's or higher educational degree. An advanced degree will be an added advantage.
• 2. Minimum of 5 years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience
• 3. A minimum of 2 years of experience of Clinical Documentation Specialist experience.
• 4. RN, NP, or PA licensure
• 5. Demonstrated experience in leading a CDI team in a healthcare setting.
• 6. Extensive knowledge of CMS and CCDS guidelines.
• 7. Strong leadership and team management skills, with the ability to motivate and guide a team towards achieving high-quality outcomes.
• 8. Excellent communication and interpersonal skills, with the ability to collaborate effectively with healthcare providers and administrators.
• 9. Proficiency in using healthcare information systems and software.
• 10. Certification in Clinical Documentation Improvement (CCDI) or equivalent is desirable.

This is an exciting opportunity for a dedicated healthcare professional to lead a team in enhancing the quality of clinical documentation. If you have the required skills and experience and are passionate about improving healthcare quality, we would love to hear from you.

A bit about us:

We are a large, full-service hospital organization providing a wide range of medical services including emergency care, heart and cancer treatment, maternity with a Level II NICU, and advanced surgical procedures like robot-assisted surgery.

Why join us?

• Excellent Medical, Dental, Vision
• Growth Opportunity
• Established Healthcare Organization
• Hybrid work environment
• Relocation Assistance

#healthcare #medical #cms #acute-care #surgical #emergency-department #clinical-documentation #ccds #clinical-coding #intesive-care #post-acute-care-unit #tier4