Clinical Documentation Specialist RN

4 days ago


Naples, Florida, United States Physicians Regional - Pine Ridge Full time
Clinical Documentation Specialist RN Job Description

About the Role:

The Clinical Documentation Specialist RN will play a crucial role in ensuring the accuracy and quality of patient records at Physicians Regional - Pine Ridge. This position requires a strong clinical background and excellent communication skills to work with healthcare providers and staff.

Key Responsibilities:

  • Review medical records and clinical indicators to identify potential gaps in documentation
  • Collaborate with providers to ensure complete and accurate medical records
  • Educate physicians and healthcare providers on clinical documentation improvement and the importance of accurate documentation
  • Conduct concurrent and retrospective reviews of inpatient medical records to evaluate documentation and utilization of acute care services

Requirements:

  • Current, valid RN license or RHIA, RHIT, or CCS credential
  • Minimum five years acute hospital nursing experience
  • Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management, and/or inpatient coding
  • Minimum one-year auditing experience
  • ICU/Critical Care experience and prior experience in clinical documentation improvement, ICD coding, and MS-DRGs are highly desirable

What We Offer:

Physicians Regional - Pine Ridge is committed to providing a supportive and collaborative work environment. As a Clinical Documentation Specialist RN, you will have the opportunity to work with a talented team of healthcare professionals and contribute to the improvement of patient care.



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