CLINICAL DOCUMENTATION COORD

Wellington Regional Medical Center; West Palm Beach (FL); On-site; USD 60,000 - 80,000; Full time

Benefits offered by this job

Challenging and rewarding work environment

Competitive Compensation & Generous Paid Time Off

Excellent Medical, Dental, Vision and Prescription Drug Plans

401(K) with company match and discounted stock plan

Educational Assistance

Career development opportunities

HealthStream online learning catalogue

Job summary

Wellington Regional Medical Center is looking for a full-time Registered Nurse to enhance clinical documentation quality. Responsibilities include educating staff and collaborating with physicians for accurate medical records.

The position offers excellent benefits including competitive compensation, generous time off, and exceptional healthcare plans.

Qualifications

• Must have a current license as a Registered Nurse.
• Minimum of 2 years of experience as a CDI in an acute care setting.
• Critical care, medical/surgical or emergency department nursing preferred.

Responsibilities

• Improve overall quality and completeness of clinical documentation.
• Educate health care team members on clinical documentation.
• Facilitate interaction with physicians for documentation clarity.

Skills

Clinical Documentation Improvement

Professionalism

Teamwork

Education

Registered Nurse (RN) license

MD/MBBS

RHIA/RHIT, CCS

Certification for CDI (CCDS, CDIP)

Job description

Responsibilities

Full‑time 40‑hour week, day shift, full benefits.

• Treat everyone as a guest by making a good first impression, anticipating needs and displaying service recovery skills.
• Demonstrate professionalism and excellence by looking professional, taking responsibility for our actions and delivering excellence in our everyday work.
• Practice teamwork by actively participating in decision‑making and process improvement, communicating effectively and focusing on the problem/issue, not the person.

Assumes responsibility and accountability for improving the overall quality and completeness of clinical documentation. Promotes a partnership between concurrent clinical reviewers, medical record coders and physicians to improve documentation and reimbursement. Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians, advocating for appropriate reimbursement. Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patient’s true severity of illness, intensity of care, and risk of mortality. Educates all members of the health care team on an ongoing basis.

Benefits

• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• Educational Assistance
• SoFi Student Loan Refinancing Program
• Career development opportunities across UHS and its 300+ locations!
• HealthStream online learning catalogue with plenty of free CEU courses

Qualifications

• RN (current license as a Registered Nurse)
• MD/MBBS
• RHIA/RHIT, CCS
• Current certification(s) for CDI (CCDS, CDIP) or obtain within a year.
• Minimum of 2 years of experience as a CDI in an acute care setting, (If RN, Critical Care, Medical/Surgical or Emergency department nursing preferred).

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.