Inpatient Clinical Documentation Specialist

Lee Health; Cape Coral (FL); On-site; USD 46,000 - 62,000; Full time

Job summary

Lee Health in Cape Coral, FL, seeks a Quality Documentation Specialist (QDS) to clarify ambiguous clinical documentation and ensure accurate representation of patient severity and risk of mortality.

The role requires a Bachelor's degree (BSN preferred), at least 5 years of inpatient nursing experience, active Florida RN license, and CCDS certification within 6 months after 3 years of service; Epic proficiency and strong communication are essential.

Qualifications

• Bachelor's degree required; BSN preferred.
• Minimum 5 years of inpatient clinical nursing experience.
• CCDS certification within 6 months after 3 years of active employment.
• Florida RN license active.
• Strong interpersonal communication and analytical skills; Epic proficiency.

Responsibilities

• Clarify ambiguous or incomplete clinical documentation.
• Ensure diagnoses accurately reflect severity and risk of mortality.
• Review medical records with physicians, nurses, and providers.
• Apply coding guidelines and payer regulations after training.

Skills

Interpersonal communication

Analytical skills

Computer skills

Epic proficiency

Inpatient nursing experience

CCDS certification

Education

Bachelor's degree

BSN preferred

Tools

Epic

Job description

Lee Health in Cape Coral, FL, seeks a Quality Documentation Specialist (QDS) to clarify ambiguous clinical documentation and ensure accurate representation of patient severity and risk of mortality.

The role requires a Bachelor's degree (BSN preferred), at least 5 years of inpatient nursing experience, active Florida RN license, and CCDS certification within 6 months after 3 years of service; Epic proficiency and strong communication are essential.