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Clinical Documentation Specialist Lead

2 months ago

Lady Lake Florida, United States UF Health Full time
Job Summary

UF Health is seeking a highly skilled Clinical Documentation Specialist Lead to join our team. As a key member of our Clinical Documentation Improvement (CDI) team, you will be responsible for ensuring the accuracy and completeness of patient records, identifying areas for improvement, and providing education and training to staff.

Key Responsibilities
  • Quality Review and Assessment: Conduct ongoing quality reviews and assessments of inpatient hospital charts to ensure accuracy and completeness.
  • Audit and Analysis: Perform audits on the accuracy of clinical reviews and physician queries, and analyze claims denied for coding, documentation, and clinical validation.
  • Education and Training: Develop and deliver educational programs to improve the expertise of CDI staff in coding and quality, and provide ongoing training and support.
  • Communication and Collaboration: Coordinate reviews and responses relating to quality reviews, queries, and clinical denials, and communicate effectively with internal and external stakeholders.
  • Administrative Duties: Oversee the administrative duties of the CDI team, including Kronos, PTO requests, staff schedules, and productivity/accuracy reports.
Requirements
  • Education: Graduate of an accredited school of nursing with current RN licensure in the State of Florida or Certified Clinical Documentation Specialist (CCDS).
  • Licensure/Certification/Registration: Registered Nurse (RN) or Certified Clinical Documentation Specialist (CCDS).
  • Special Skills/Qualifications/Additional Training/Experience Required: Minimum 5 years of recent clinical experience in a hospital setting, minimum 5 years recent experience as a CDI Specialist, and strong knowledge of ICD-10 CM/PCS and proficiency with Microsoft Windows Operating Systems and Office applications.