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Clinical Documentation Specialist RN

1 month ago

Pensacola, Florida, United States Baptist Health Care Full time
Clinical Documentation Specialist RN Job Description

Baptist Health Care is seeking a skilled Clinical Documentation Specialist RN to facilitate accurate documentation for severity of illness and quality in the medical record. This role involves extensive record review, interaction with physicians, health information management professionals, and nursing staff.

Key Responsibilities:
  • Review medical records for completeness and accuracy for severity of illness (SOI) and quality using clinical documentation improvement strategies.
  • Perform accurate and timely medical record review.
  • Recognize opportunities for documentation improvement.
  • Initiate clinical documentation improvement severity worksheets for inpatients.
  • Formulate clinically credible documentation clarifications.
  • Request documentation clarifications as appropriate for SOI, core measures, and patient safety.
  • Follow up timely on all cases and resolution of those cases with clinical documentation clarifications.
  • Participate in task force meetings.
  • Communicate with HIM coding staff and resolve discrepancies.
  • Accurately input data into electronic clinical documentation improvement tools.
  • Understand and support clinical documentation improvement strategies.
  • Maintain current knowledge and certification.
Qualifications:
  • Associates Degree in Nursing or Technical Diploma/Certificate in Nursing required.
  • 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU required.
  • Registered Nurse licensed in the State of Florida or eligible compact state required.