NICU Clinical Documentation Integrity Contract $78.11/hr. StaffFlex CFD

Texas Health Huguley FWS; Tallahassee (FL); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading health organization seeks a Clinical Documentation Specialist to support documentation integrity in a remote role. The position involves collaboration with healthcare providers to ensure accurate medical records, compliance with documentation guidelines, and effective communication with physicians, with a focus on quality metrics and continuous professional growth.

Qualifications

• Minimum 5 years of nursing experience, preferably in NICU.
• 2 years of recent CDI NICU chart reviews.
• Knowledge of APR-DRG and SOI/ROM drivers.

Responsibilities

• Review medical records for compliance and completeness.
• Educate the care team on documentation guidelines.
• Participate in departmental meetings for ongoing development.

Skills

Communication

Organization

Multitasking

Education

BSN or higher in healthcare field

Job description

Job Description - NICU Clinical Documentation Integrity Contract $78.11/hr. StaffFlex CFD (25024723)

Job Description

NICU Clinical Documentation Integrity Contract $78.11/hr. StaffFlex CFD (Remote)

Job Number:

25024723

Description

Under the supervision of the Director of Clinical Documentation Integrity, the Clinical Documentation Specialist (CDS) collaborates with physicians, nursing, and HIM coders to ensure accurate and quality documentation of clinical conditions and procedures. The CDS supports appropriate severity of illness, risk of mortality, and complexity of care documentation, adhering to departmental and organizational standards. Responsibilities include educating the care team on documentation guidelines, reviewing medical records for compliance, and supporting documentation strategies to improve accuracy and regulatory compliance. The role involves effective communication with healthcare providers, participation in departmental meetings, and ongoing professional development.

Shift: Days

Location: AdventHealth Hospital within CFD Division (Remote)

Principal Duties:

• Review medical records for compliance, completeness, and accuracy regarding SOI, ROM, and quality metrics.
• Complete timely record reviews and input data into CDI software accurately.
• Support and educate the care team on documentation guidelines, including Medicare updates.
• Communicate effectively with physicians and healthcare providers to clarify documentation and resolve discrepancies.
• Participate in department meetings and educational activities.
• Maintain professional growth and proficiency through ongoing education.
• Perform chart audits and identify documentation improvement opportunities.
• Achieve key performance metrics, including physician response and agreement rates.

Qualifications:

• Excellent communication and physician relations skills.
• Strong organizational and multitasking abilities.
• Experience with clinical documentation reviews, Medicare risk adjustment, and coding.
• Minimum 5 years of nursing experience, preferably in NICU, with at least 2 years of recent CDI NICU chart reviews.
• Knowledge of APR-DRG, SOI/ROM drivers, and ability to send impactful queries.
• BSN or higher in healthcare field with 2 years of CDI experience, or 3+ years of recent CDI experience.

Job Details:

• Department: Quality/Clinical Effectiveness
• Organization: AdventHealth Central Florida
• Primary Location: US-Florida