Clinical Documentation Specialist

Nemours-Children; Orlando (FL); On-site; USD 70,000 - 100,000; Full time

Job summary

Nemours is seeking a Clinical Documentation Specialist in Orlando, FL. The role involves concurrent and retrospective reviews of medical record documentation to ensure accuracy and completeness, supporting ICD-10 coding, DRG assignment, and quality reporting.

CDI works with physicians, coding, and quality teams to educate providers on risk stratification and documentation improvement. Collaboration with clinical teams to develop templates and education is essential.

Qualifications

• RN license active and unrestricted in Florida or Delaware.
• CDI certification and/or coding certification preferred.
• Extensive knowledge of medical terminology, anatomy, physiology, pharmacology, and disease processes.

Responsibilities

• Review inpatient medical records for documentation opportunities within 2 days of admission.
• Attend multidisciplinary patient rounds with care team.
• Communicate with care team regarding documentation opportunities and ICD-10 specificity.
• Develop tools and educational programs to support documentation improvement.
• Identify trends for improvement and report findings to attending group.

Skills

Medical terminology

Anatomy & physiology

Pharmacology

Disease processes

Clinical validation

Education

Active RN license in FL or DE

CDI or coding certification preferred

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