Quality Documentation Specialist

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 professional 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 professional 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:

Graduate of an accredited school of nursing. BSN or BS in a related healthcare field.

Experience:

Minimum of five years recent diverse clinical nursing experience required, preferably in acute care.

Certification:

Certification as a Documentation Improvement Specialist within 2 years is required (a 6-month window will be given to allow a second attempt if QDS fails first exam attempt).

License:

Current FL RN license.

Other:

Strong interpersonal, communication (verbal, non-verbal and listening), analytical and computer skills.

US:

FL:

Cape Coral