Clinical Documentation Specialist RN

5 days ago


Naples FL United States Physicians Regional - Pine Ridge Full time
Clinical Documentation Specialist RN

Job Description This position is 100% onsite, to allow for better communication and coordination with our staff and providers. The Clinical Documentation Specialist (CDS) performs clinical documentation improvement activities in an effort to support accuracy and quality of the patient records and to ensure that coded diagnoses are an accurate reflection of the patient's clinical status and care. The role of the CDS involves reviewing the medical record documentation and clinical indicators and working with providers to ensure a complete and accurate medical record. The CDS will identify potential gaps in clinical documentation for inpatient and payer populations as directed throughout the hospitalization. Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record. Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. Skills and Experience: Must possess a current, valid RN license or an RHIA, RHIT, or CCS credential. Minimum five years acute hospital nursing experience (e.g. medical/surgical unit, intensive care). Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management and/or inpatient coding strongly desired. Minimum one-year auditing experience strongly desired. ICU/Critical Care experience strongly desired. Prior experience in clinical documentation improvement, ICD coding, and MS-DRGs preferred. Prior experience educating physicians/providers preferred. Prior experience in a clinical documentation improvement department or as a consultant strongly desired. Must possess a comprehensive knowledge of medical terminology, disease processes, and clinical competency. INDPR



  • Naples, FL, United States Physicians Regional - Pine Ridge Full time

    Clinical Documentation Specialist RN Job Description This position is 100% onsite, to allow for better communication and coordination with our staff and providers. The Clinical Documentation Specialist (CDS) performs clinical documentation improvement activities in an effort to support accuracy and quality of the patient records and to ensure that coded...


  • Naples, FL, United States Physicians Regional - Pine Ridge Full time

    Clinical Documentation Specialist RN Job Description This position is 100% onsite, to allow for better communication and coordination with our staff and providers. The Clinical Documentation Specialist (CDS) performs clinical documentation improvement activities in an effort to support accuracy and quality of the patient records and to ensure that coded...


  • Naples, Florida, United States Physicians Regional - Pine Ridge Full time

    Clinical Documentation Specialist RN Job DescriptionThis position is 100% onsite, allowing for better communication and coordination with our staff and providers.The Clinical Documentation Specialist (CDS) performs clinical documentation improvement activities to support accuracy and quality of patient records and ensure coded diagnoses accurately reflect...


  • , CA, United States Optum Full time

    Optum Clinical Documentation Integrity SpecialistAt Optum, we're dedicated to delivering care and improving health outcomes for millions of people worldwide. As a Clinical Documentation Integrity Specialist, you'll play a critical role in ensuring the accuracy and completeness of clinical documentation in our inpatient medical records.Key...


  • , CA, United States Optum Full time

    Optum Clinical Documentation Specialist Job DescriptionAt Optum, we're dedicated to delivering care and improving health outcomes for millions of people around the world. As a Clinical Documentation Specialist, you'll play a critical role in ensuring the accuracy and completeness of clinical documentation, which is essential for providing high-quality care...


  • , CA, United States Optum Full time

    Optum Clinical Documentation Improvement SpecialistAt Optum, we're dedicated to delivering care and technology to help millions of people live healthier lives. As a Clinical Documentation Improvement Specialist, you'll play a critical role in improving health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to...


  • , MD, United States ChristianaCare Full time

    Job Title: Clinical Documentation SpecialistChristianaCare is seeking a skilled Clinical Documentation Specialist to support the improvement of inpatient clinical documentation quality, accuracy, and completeness.Key Responsibilities:Collaborate with program leadership to develop and implement clinical documentation education programs for CDI specialists and...


  • , CA, United States CPMC Van Ness Campus Full time

    Job SummaryWe are seeking a skilled Clinical Documentation Specialist to join our team at CPMC Van Ness Campus. As a Clinical Documentation Specialist, you will play a critical role in ensuring the accuracy and completeness of patient medical records.Key ResponsibilitiesConduct thorough reviews of patient medical records to identify areas for improvement and...


  • , CA, United States CPMC Van Ness Campus Full time

    Job SummaryWe are seeking a skilled Clinical Documentation Specialist to join our team at CPMC Van Ness Campus. As a Clinical Documentation Specialist, you will play a critical role in ensuring the accuracy and completeness of patient medical records.Key ResponsibilitiesConduct thorough reviews of patient medical records to identify areas for improvement and...


  • Jacksonville, FL, United States Saint Vincent's Medical Center Riverside Full time

    Clinical Document Improve Specialist RNDetails * Department: Total Quality Management * Schedule: Full-Time; Days; Monday - Friday 8am-4:30pm * Hospital: Ascension St. Vincents Riverside * Location: Jacksonville, Florida * CDI experience Benefits Paid time off (PTO) Various health insurance options & wellness plans Retirement benefits including employer...


  • Staten Island, NY, United States Clinical Management Consultants Full time

    Are you an experienced and driven RN or healthcare professional looking for an exciting leadership CDI opportunity? This New York Hospital is seeking a highly qualified Manager of Clinical Documentation Improvement (CDI) to join our dynamic team. As the Manager of CDI, you will play a vital role in optimizing patient care, revenue integrity, and compliance...


  • Staten Island, NY, United States Clinical Management Consultants Full time

    Are you an experienced and driven RN or healthcare professional looking for an exciting leadership CDI opportunity? This New York Hospital is seeking a highly qualified Manager of Clinical Documentation Improvement (CDI) to join our dynamic team. As the Manager of CDI, you will play a vital role in optimizing patient care, revenue integrity, and compliance...


  • Jacksonville, FL, United States Saint Vincent's Medical Center Riverside Full time

    Clinical Document Improve Specialist RN Total Quality Management * Schedule: Full-Time; Monday - Friday 8am-4:30pm * Hospital: Various health insurance options & wellness plans Retirement benefits including employer match plans Long-term & short-term disability Employee assistance programs (EAP) Parental leave & adoption assistance Tuition...


  • Long Beach, CA, United States VirtualVocations Full time

    A company is looking for a Remote Clinical Documentation Specialist (CDI) Team. Key Responsibilities: Oversee daily review assignments for CDI Specialists Facilitate appropriate clinical documentation to support coding Collaborate with healthcare team members to ensure accurate medical record documentation Required Qualifications: Bachelor's...


  • Salisbury, MD, United States TidalHealth Full time

    Why work at TidalHealth? Looking for a rewarding place to work? Choose TidalHealth. Our hospitals have been named among the Top 5 percent of all U.S. hospitals by Healthgrades and a five-star hospital by the Centers for Medicare & Medicaid Services. Located just 30 minutes from the beach, TidalHealth offers the widest array of specialty and subspecialty...


  • Kennewick, WA, United States Trios Health Full time

    Job DescriptionClinical Documentation Specialist coordinates and collaborates extensively with the physicians and coding staff to improve quality and completeness of documentation of care provided; Facilitates modifications to clinical documentation. Captures clinical severity which is later translated into coded data to support the level of service rendered...


  • Kennewick, WA, United States Trios Health Full time

    Job DescriptionClinical Documentation Specialist coordinates and collaborates extensively with the physicians and coding staff to improve quality and completeness of documentation of care provided; Facilitates modifications to clinical documentation. Captures clinical severity which is later translated into coded data to support the level of service rendered...


  • Kennewick, WA, United States Trios Health Full time

    Clinical Documentation Specialist coordinates and collaborates extensively with the physicians and coding staff to improve quality and completeness of documentation of care provided; Facilitates modifications to clinical documentation. Captures clinical severity which is later translated into coded data to support the level of service rendered to relevant...


  • Kennewick, WA, United States Trios Health Full time

    Clinical Documentation Specialist coordinates and collaborates extensively with the physicians and coding staff to improve quality and completeness of documentation of care provided; Facilitates modifications to clinical documentation. Captures clinical severity which is later translated into coded data to support the level of service rendered to relevant...


  • Jacksonville, FL, United States Saint Vincent's Medical Center Riverside Full time

    Clinical Document Improve Specialist RN Details * Department: Total Quality Management * Schedule: Full-Time; Days; Monday - Friday 8am-4:30pm * Hospital: Ascension St. Vincents Riverside * Location: Jacksonville, Florida * CDI experience Benefits Paid time off (PTO) Various health insurance options & wellness plans Retirement benefits including...