RN Specialist – Clinical Documentation

Role Overview

• Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the clinical documentation improvement strategies.
• Performs accurate and timely medical record review.
• Recognizes opportunities for documentation improvement.
• Initiates clinical documentation improvement severity worksheet for inpatients.
• Formulates clinically credible documentation clarifications.
• Requests documentation clarifications as appropriate for SOI, core measures, and patient safety.
• Follows up timely on all cases and resolution of those cases with clinical documentation clarifications.
• Participates in task force meetings.
• Communicates with HIM coding staff and resolves discrepancies
• Accurately inputs data into electronic clinical documentation improvement tool.
• Understands and support clinical documentation improvement strategies.
• Maintains current knowledge/certification.

Requirements

• Associates Degree Nursing Required or
• Technical Diploma/Certificate Nursing Required
• 5 years Adult acute care experience in med/surg, critical care, emergency room, or PACU Required
• Registered Nurse Licensed State of Florida or eligible compact state Required