JOB DESCRIPTION The Clinical Documentation Specialist- RN facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the clinical documentation improvement process is a key role.
RESPONSIBILITIES- 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.
QUALIFICATIONSMinimum Education- Associates Degree Nursing Required or
- Technical Diploma/Certificate Nursing Required
Minimum Work Experience- 5 years Adult acute care experience in med/surg, critical care, emergency room, or PACU Required
Licenses and Certifications- Registered Nurse Licensed State of Florida or eligible compact state Required
ABOUT US Baptist Health Care is a not-for-profit health care system committed to improving the quality of life for people and communities in northwest Florida and south Alabama. The organization includesthree hospitals, four medical parks,Andrews Institute for Orthopaedic & Sports Medicine, and an extensive primary and specialty care provider network. With more than 4,000 team members, Baptist Health Care is one of the largest non-governmental employers in northwest Florida.
Baptist Health Care, Inc. is an Equal Opportunity Employer. BHC maintains and enforces a policy that prohibits discrimination against any workforce members or applicants for employment because of sex, race, age, color, disability, marital status, national origin, religion, genetic information, or other category protected by federal, state or local law. Certain positions may require a Level 2 Background check through AHCA. Additional information about this requirement can be found here: Florida Care Provider Background Screening Clearinghouse