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Clinical Documentation Integrity Specialist
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What they do
A Clinical Documentation Specialist works with information technology systems and applications in health care organizations. Assists clinicians and staff with technology and implementing new systems. Creates systems for organizing and interpreting data and information for clinical trials. Records and manages clinical information about patients, including health assessments and diagnoses, test results, treatments, and follow up care requirements. Reviews and maintains patient records.
$74,453 / year median in the U.S.
+0% projected growth
Job Description
- BayCare Health System Our network consists of 16 community-based hospitals, a long-term acute care facility, home health services, outpatient centers and thousands of physicians.
Title:
Clinical Documentation Integrity Specialist Facility:
Remote (Must Reside in the State of Florida)Responsibilities:
Professional Registered Nurse with sound clinical knowledge and strong critical thinking skills. Accountable for the integrity and accuracy of advanced practice clinical documentation through concurrent interaction with providers and other members of the healthcare team. Ensure clinical documentation integrity through proficient delivery of the Clinical Documentation Integrity (CDI) program workflows, including obtaining appropriate provider diagnoses documentation into the medical record in order to achieve legitimate code assignment and accurate reporting of the patient's condition and care provided. Contribute to process improvement efforts by designing, developing, implementing and supporting the CDI Program reporting and analytics. Collaborate with the physician advisor to achieve CDI program goals and accurate documentation representation of medical necessity for appropriate patient status. Promote the capture of clinical severity to support the level of service rendered to relevant patient populations. Perform other duties as assigned. BayCare offers a competitive total reward package including: Benefits (Medical, Dental, Vision) Paid Time Off Tuition Assistance 401K Match and additional yearly contribution Annual performance appraisals and team award bonus Family resources and wellness opportunities Community perks and discountsExperience:
Required- 2 years RN experience in Acute Care within the last 5 years Preferred
- 2 years Clinical Documentation Certification Required
- RN•Florida Department of Health Preferred•CCDS•Association of Clinical Documentation Integrity Specialist Preferred•CCS•American Health Information Management Association Preferred•CPC•American Academy of Professional Coders Education Required•Associates•Nursing Preferred•Bachelors•
Nursing Status:
Full Time, Exempt:
Yes Shift Hours:
8:00am- 4:30pm (Flexible) Equal Opportunity Employer Veterans/Disabled