Clinical Documentation Specialist

Nemours; Orlando (FL); On-site; USD 75,000 - 105,000; Full time

Job summary

Nemours seeks a Clinical Documentation Specialist in Orlando, FL to review medical records for documentation accuracy and completeness, ensuring ICD-10 coding and DRG assignment reflect patient care. You will collaborate with physicians, quality teams and revenue cycle to improve documentation and education.

Responsibilities include rounds with the care team, identifying documentation gaps, and developing tools and education for providers to support compliant EHR documentation and risk

Qualifications

• Extensive knowledge of medical terminology, anatomy, physiology, pharmacology and disease processes.
• Registered Nurse with pediatric nursing experience.
• CDI and/or coding certification preferred.

Responsibilities

• Review inpatient medical 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 and track data in Epic.
• Identify trends/opportunities for improvement in documentation habits and report to attending group.

Skills

Medical terminology

Nursing background

EHR / Epic experience

Communication with care team

Education

Registered Nurse

Pediatric nursing

Tools

Epic EHR

Job description

Nemours is seeking a Clinical Documentation Specialist in Orlando, FL

Responsible for concurrent and retrospective reviews of medical record documentation to ensure that the medical record is accurate and complete and reflects the patients condition as well as services performed. The Clinical Documentation Integrity (CDI) Specialist support accurate ICD 10 CM/PCS coding, DRG assignment, severity of illness, risk of mortality, reimbursement, risk adjustment, and quality reporting.

CDI works with coding, physicians, physician advisors, quality teams, as well as utilization management and other revenue cycle and clinical teams to support accurate data. in delivering documentation education to providers including education of risk stratification, chronic conditions, and appropriate documentation to support billing.

Participate in development of templates, smart phrases, other documentation tools in collaboration with clinical teams to support documentation improvement initiatives .

Monitor and support improvement of patient chart documentation for both inpatient and outpatient settings

Essential Functions

• Review inpatient medical records within 2 days of admission for documentation opportunities and problem list accuracy. Analyzes clinical status of patient, current treatment plan and past medical history and using clinical validation to identify potential gaps in physician documentation
• 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. Verify the response rate from care team to clarify diagnosis
• 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

Requirements

• 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 for NCH DE and/or the state of Florida for NCH FL
• CDI certification and/or coding certification preferred

About Us

Nemours Children's Health is an internationally recognized pediatric health system serving more than 1.7 million patient encounters each year. We deliver care across six states through two freestanding children's hospitals - Nemours Children's Hospital, Delaware and Nemours Children's Hospital, Florida - along with a network of more than 80 primary, urgent, and specialty care practices and more than 40 hospital partnerships.

Backed by the Nemours Foundation and Alfred I. duPont Trust, our $1.7B nonprofit system is dedicated to improving children's health through clinical care, research, education, advocacy, and prevention. Our Whole Child Health approach focuses equally on prevention and treatment, partnering with communities to help every child thrive.

Inclusion and belonging guide our strategy and growth. We are committed to culturally relevant care, reducing health disparities, and fostering an environment where every associate, patient, and family feels supported and valued.

Learn more at Nemours.org .