Post-Acute Clinical Documentation Integrity Specialist

Sarasota Memorial Health Care System; Sarasota (FL); On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Paid Time Off

Tuition Reimbursement

Discounted Medical Plans

Flexible Spending Accounts

Life Insurance

Disability Insurance

Retirement Savings Plan 403b

On Campus Parking

Job summary

The Sarasota Memorial Health Care System is seeking a Post-Acute Clinical Documentation Integrity Specialist to improve the quality of clinical documentation for post-acute inpatient coding. You will review daily admissions, manage concurrent reviews through discharge, and query physicians to ensure accurate reflection of patient acuity.

This role also provides documentation and coding education as needed, collaborating with care teams to support outcomes reporting and profiling.

Qualifications

• Bachelor’s degree (prefer BSN) and active RN license in Florida or MD equivalent.
• Minimum three years of clinical experience in post-acute settings (CDIS, SNF, IRF, LTCH).
• Ability to communicate verbally and in writing; ability to work independently and in a team.

Responsibilities

• Facilitate improvement in quality and completeness of clinical documentation to support coding in the post-acute inpatient setting.
• Review daily new admission post-acute inpatient records and conduct concurrent reviews until discharge.
• Query physicians on diagnostic or procedure specificity to reflect patient acuity and resources used.
• Provide documentation and coding education as needed.

Skills

Verbal and written communication

Multi-tasking

Team collaboration

Problem solving

Education

Bachelor's degree in nursing

Associate degree in Nursing (ASN) with substitution

Tools

Adobe Acrobat

Microsoft Office (Excel, PowerPoint, Word)

Job description

Department

Revenue Cycle

Job Summary

The Post-Acute Clinical Documentation Integrity Specialist is responsible for facilitating the improvement in the overall quality and completeness of clinical documentation to support coding in the post-acute inpatient setting, and will be responsible for reviewing daily new admission inpatient post-acute medical records, as well as, subsequent reviews while patient is still in-house (concurrent) until discharged. The Specialist is also responsible for querying physicians on specificity of diagnosis or procedures performed in order to ensure the account appropriately reflects the patient’s acuity and resources used to care for the patient resulting in complete and accurate profiling and reporting outcomes. In addition, the Specialist will provide documentation and coding education as needed.

Required Qualifications

- Require a Bachelor’s degree (preferably BSN). Associate degree in Nursing (ASN) and two (2) years of relevant work experience in an acute or post-acute setting can substitute for the required degree.
- Require a minimum of three (3) years of clinical experience in the area of hire (CDIS, SNF, IRF, or LTCH).
- Require an active Florida Registered Nurse (RN) license or Medical Doctor (MD) equivalent.

Preferred Qualifications

- Prefer the ability to communicate verbally and in writing.
- Prefer the ability to multi-task, shift priorities, and demonstrate decision-making ability.
- Prefer the ability to work independently and collaboratively in a team environment.
- Prefer certification as Certified Documentation Improvement Professional (CDIP) or Certified Clinical Documentation Specialist (CCDS).
- Prefer Certified Rehabilitation Registered Nurse (CRRN) Certification.
- Prefer knowledge of Prospective Payment System methodology in area of hire (Skilled Nursing Facility Prospective Payment System - Patient Driven Payment Model (PDPM); Inpatient Rehabilitation Facility – Case Mix Group (CMG); Long Term Care Hospital – MS-LTC-DRG).
- Prefer proficiency in Adobe Acrobat and Microsoft Office suite, specifically Excel, PowerPoint, and Word.

Reputation. Community. Impact. Growth.

Every day, our patients at Sarasota Memorial Health Care System receive a first-class experience in care from a team on a mission to deliver the highest level of care in America. In the process of rising to that challenge, one by one, our people are finding their purpose and feeling their impact. Now it is your turn to see yourself here.

Sarasota Memorial Hospital was recently recognized again by ranking #1 Hospital in the Region by the U.S. News's Best Hospital report by scoring a Perfect 10! Not only that, but SMH was also designated at a national "standout" hospital for earning top ratings in all evaluated conditions and procedures - an accomplishment achieved by less than 1% of the 4000+ hospitals. Our system has also earned Magnet® recognition from the American Nurses Credentialing Center (ANCC), as well as these additional accolades: Gallup Great Workplace 2018; recipient of an "A" grade for Patient Safety. Sarasota Memorial Hospital is Magnet designated and the only provider of Level II trauma services, obstetrical services, and Level III neonatal intensive care in Sarasota County.

The benefits of being the best:

Our commitment to becoming the best community hospital and health care system means providing the best possible benefits to our people. Some highlights:

Total Rewards Package

• Paid Time Off (start earning PTO on day one of employment)
• Tuition Reimbursement
• Discounted Medical, Prescription, Dental, Vision Benefit Plans for Full & Part-Time Employees
• Flexible Spending Accounts (Health Care and Dependent Care) - Pre-Tax Dollars
• Life Insurance
• Disability Insurance
• Retirement Savings Plan: 403b
• Sarasota Campus for now - Discounted Child Care & Before and After School Program and Summer Camp!
• Bereavement Leave
• Free Parking
• On Campus Dining w/ a 10% discount
• Credit Union w/ teller machines on campus
• Direct Deposit
• Free Wellness Screening
• Free confidential counseling services
• Employee Discount Programs
• Recognition Programs
• Referral Programs
• Tremendous growth opportunities for hard workers!

Employment Screening Requirements

As part of Sarasota Memorial Health Care System’s commitment to keeping people safe, all individuals providing care to vulnerable populations are required to undergo background screening through The Florida Care Provider Background Screening Clearinghouse. https://info.flclearinghouse.com/