Clinical Documentation Integrity Specialist

The Nemours Foundation; Orlando (FL); On-site; USD 85,000 - 110,000; Full time

Job summary

Nemours is seeking a Clinical Documentation Specialist in Orlando, FL to perform concurrent and retrospective reviews of medical records, ensuring accurate and complete documentation that reflects patient condition and services performed.

You will support ICD-10-CM/PCS coding, DRG assignment, severity of illness and risk adjustment, collaborate with physicians, coding, quality and revenue cycle teams, and develop templates and education to improve documentation.

Qualifications

• Extensive knowledge of medical terminology, anatomy, physiology, pharmacology and disease processes.
• Registered Nurse preferably with Pediatric nursing and/or CDI experience.
• Minimum of 5 years experience in Pediatric nursing.
• Licensed registered nurse active and unrestricted in the State of Delaware or Florida.
• CDI certification and/or coding certification preferred.

Responsibilities

• Review inpatient records within 2 days of admission for documentation opportunities and problem list accuracy.
• Attend multidisciplinary patient rounds with care team.
• Communicate with care team regarding documentation opportunities and ICD 10 specificity-verbal or written queries and track this data in Epic.
• In collaboration with physician champion, CDI designs and implements specific tools and educational programs to support medical record physician EHR documentation.
• Identify and arrange education for new providers soon after onboarding- develop educational offerings for new providers.
• Identify trends/opportunities for improvement in documentation habits of service line and report that information to the attending group in education session.
• Expert knowledge of EHR use and tools available for clarification presentation and tracking.
• Maintain expert knowledge of current changes of ICD 10 requirements and educate providers to needed changes in documentation.
• Understand DRG methodologies including APR DRG and MS DRG.
• Review denials and understand root causes for process.
• Identifies strategies for sustained work process changes that facilitate complete and accurate clinical documentation.
• Maintain open communication with Hospital and PB coding staff, coding integrity, physician champion and division leaders.

Skills

Medical terminology

Pediatric nursing

CDI experience

RN licensure

Education

RN licensure (Delaware or Florida)

Job description

Nemours is seeking a Clinical Documentation Specialist in Orlando, FL to perform concurrent and retrospective reviews of medical records, ensuring accurate and complete documentation that reflects patient condition and services performed.

You will support ICD-10-CM/PCS coding, DRG assignment, severity of illness and risk adjustment, collaborate with physicians, coding, quality and revenue cycle teams, and develop templates and education to improve documentation.