Pediatric 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 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