Quality Documentation Specialist II
3 weeks ago
Location:Santa Barbara Professional Center -224 Santa Barbara BlvdCape Coral FL 33991
Department: CDI - Clinical Documentation
Work Type: Part Time
Shift: Shift 1/ to
Minimum to Midpoint Pay Rate:$ $45.05 / hour
SummaryThe role of the Quality Documentation Specialist (QDS) II, while incorporating the QDS level I role, is expected to demonstrate a higher level of comprehension of the concurrent review process through knowledge and experience. The QDS II is able to consistently recognize clinical indicators and use knowledge pertaining to nursing experience and deep knowledge of pathophysiology to obtain physician documentation that reflects accuracy in care and specificity of diagnoses in the patients medical record. The QDS II is able to consistently identify opportunities to query for assignment of DRG, major co-morbid conditions (MCCs) and co-morbid conditions (CCs) when clinical evidence is present. Queries written by a QDS II are consistent and yield a high level of quality and complexity based on clinical indicators, while ensuring compliance regarding all federal, state and local regulations. Queries are diverse and pertain to all patient populations within the health system.
The QDS II serves as resource person within Quality Documentation Department. Assists with general department orientation. Orients/trains new employees in chart review, query process, and quality measures, when necessary.Assists in performing second level reviews to assure the highest quality based on internal needs. Manages special projects assigned based on departmental needs. Utilizes Epic's electronic health record and 3M's Coding and Reimbursement system encoder.
This position will have a hybrid schedule.
RequirementsEducational RequirementsDegree/Diploma ObtainedProgram of StudyRequired/Preferredand/orBachelor'sRequiredBachelor'sNursingPreferredExperience RequirementsMinimum Years RequiredArea of ExperienceRequired/
Preferredand/or2 YearsCDIRequiredAdditional Requirements
Knowledge of coding guidelines and sequencing of diagnoses. Must be knowledgeable of business medicine and transitional healthcare changes.
Minimum of 5 years of diverse clinical experience.
State of Florida Licensure RequirementsLicensesRequired/Preferredand/orRegistered Nurse LicenseRequiredCertifications/Registration RequirementsCertificates/RegistrationsRequired/
Preferredand/orCCDS (Certified Clinical Documentation Specialist)Required Additional Requirements
Proficient use of 3M and Epic Teamwork. Is an invaluable asset and must be a resource for education to staff and physicians, as well as mentor new staff. Will require flexible hours to accommodate training audience. The QDS II contributes to staff meetings as well as shares ideas, areas of improvements and educational opportunities for the department.
US:FL:Cape Coral
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