Description

Position Summary

Under general supervision of the Clinical Documentation Integrity Program Manager, the Clinical Documentation Specialist II is responsible for improving overall quality and completeness of clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physician, case management, nursing staff, other patient caregivers and coding staff. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician outcomes.

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Qualifications

EDUCATION

Required: Graduate of a foreign medical school or education recognized by the State of Florida as qualification for licensed Registered Nurse, LPN, Physician Assistant, or Advanced Practice Registered NurseDesirable: MBA, MPH, MHA or MSN

EXPERIENCE

Minimum of 2 years clinical or inpatient experience in an acute care setting required; 5 years strongly preferred. 
 

REQUIRED LICENSURE/REGISTRATION/CERTIFICATIONS

Must be either: licensed in the State of Florida as a Registered Nurse, LPN, Physician Assistant or APRN licensed in the State of Florida or a graduate of a foreign medical school (with ECFMG Certification preferred but not required) Certified in one of the following within 2 years of hire into the position:Certification in clinical documentation improvement through ACDIS or AHIMA (CCDS or CDIP) strongly desired.Certified in coding (CCS) preferred.

OTHER QUALIFICATIONS

Familiarity with coding concepts and coding software desired.Knowledge of care delivery documentation systems and related medical record documents.Knowledge of age-specific needs and the elements of disease processes and related procedures.Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.Excellent written and verbal communication skills.Excellent critical thinking skills.Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff, and health information systems coding staff.Working knowledge of inpatient admission criteria.Ability to work independently in a time-sensitive environment.Computer literacy and familiarity with the operation of basic office equipment.Assertive personality traits to facilitate ongoing physician communication.Ability to stand and walk for periods of time is required in the performance of job responsibilities.Working knowledge of MS DRGs and national coding guidelines.
 

#LI-RS1

Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.