Quality 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

Location: Santa Barbara Professional Center - 224 Santa Barbara Blvd Cape Coral FL 33991

Department: CDI - Clinical Documentation

Work Type: Full Time

Shift: Shift 1/ to

Minimum to Midpoint Pay Rate: $33.37 - $45.05 / hour

Summary

Using a multidisciplinary team approach, the Quality Documentation Specialist (QDS) works to clarify ambiguous, conflicting, incomplete documentation and clinical validity of diagnoses. The QDS works to facilitate the overall quality and completeness of clinical documentation to accurately represent the severity, acuity and risk of mortality profile of the patient being treated. The QDS achieves these goals through careful review of all the information available concurrently through the patients stay. Focused communication and education with clinical professionals will be utilized, including physicians, advanced providers and nurses. A diverse, preferably, acute care clinical background is a must. Knowledge of anatomy and physiology, pathophysiology and pharmacology is utilized daily within the role. After intensive training, knowledge of official medical coding guidelines, CMS and private payer regulations related to the Inpatient Prospective Payment System will be applied to clinical reviews. The QDS will be able to analyze and interpret medical record documentation and formulate appropriate provider queries.

Requirements

Education: Bachelor's degree required, BSN preferred.

Experience: Minimum of 5 years of inpatient clinical nursing experience required. High Acuity (PCU or Critical Care) patient care preferred.

Certification: CCDS (Certified Clinical Documentation Specialist) required within 6 months after 3 years of active employment as a QDS required.

License: Current active RN License in the state of Florida required.

Other: Strong interpersonal communication (verbal, non-verbal and listening), analytical and computer skills required. Proficiency with Epic preferred.

US:FL:Cape Coral