Clinical Documentation Specialist

Clinical Documentation Specialist

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On-site,  Full-time,  Mid-Senior level

The Opportunity:

*This position is hybrid and candidates must be able to work onsite at NCH – North Hospital in Naples, FL 2 days per week.*

The CDI Specialist facilitates and obtains appropriate physician documentation for any patient clinical condition or procedure to support the appropriate severity of illness, expected risk of mortality, and complexity of care as documented in patient medical records. Extensive medical record review and interaction with physicians, nursing staff, other patient care givers and HIM coding professionals is done to ensure the documentation is complete and accurate.

Job Responsibilities:

  • Completes initial patient medical record review within 24-48 hours of patient’s admission; completes subsequent reviews of patient’s medical record reviews every 24-48 hours and enters review findings in CDE software system
  • Assigns Principal diagnosis, CC/MCC (complication and comorbidity/major complication and comorbidity), evaluate for Severity of Illness (SOI) and Risk of Mortality (ROM) on all patients while in-house. Assigns working ICD-10-CM and PCS codes and DRG (Diagnosis Related Group) using encoder in CDE software.
  • Clarifies with physicians regarding missing, unclear, unsupported or conflicting health record documentation by requesting and obtaining additional documentation from physicians when needed. Face to face physician interaction and written clarifications are used.
  • Educates key healthcare providers such as physicians, nurse practitioners, allied health professionals, nursing and care coordination regarding clinical documentation improvement, documentation guidelines and the need for accurate and complete documentation in the health record.
  • Partners with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine the working and final DRG assignment. Reviews DRG denial letters and writes denial appeal letters.
  • Collaborates with care coordination, nursing staff and other ancillary staff regarding interaction with physicians on documentation and to resolve physician clarifications prior to patient discharge.
  • Maintains and upholds all clinical documentation regulatory guidelines
  • Formulates and submits timely, well prepared appeals for reconsideration by third party administrators (payors). Including supporting documented clinical evidence, Coding/CDE Guidelines and other regulatory standards/guidelines as appropriate. Works collaboratively with co-works and management to effectively resolve root cause issues that impact payor contracts, hospital operations, or departmental to maintain reimbursement and minimize appeal requests and/or denials.


Experience We Love:

  • Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, or Emergency Department experience
  • Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrate excellent physician relations
  • Ability to organize and present information clearly and concisely; excellent computer and keyboarding skills; high degree of prioritization skills

Minimum Education

  • Current RN Licensure

Certifications:

  • CRCR Required within 9 months of hire

#LI-LS1

Join an award-winning company

Three-time winner of “Best in KLAS” 2020-2022

2022 Top Workplaces Healthcare Industry Award

2022 Top Workplaces USA Award

2022 Top Workplaces Culture Excellence Awards

  • Innovation
  • Work-Life Flexibility
  • Leadership
  • Purpose + Values

Bottom line, we believe in empowering people and giving them the tools and resources needed to thrive. A few of those include:

  • Associate Benefits We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs. 
  • Our Culture – Ensemble is a place where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation.  
  • Growth – We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement. 
  • Recognition – We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company. 

Ensemble Health Partners is an equal employment opportunity employer. It is our policy not to discriminate against any applicant or employee based on race, color, sex, sexual orientation, gender, gender identity, religion, national origin, age, disability, military or veteran status, genetic information or any other basis protected by applicable federal, state, or local laws.  Ensemble Health Partners also prohibits harassment of applicants or employees based on any of these protected categories.

Ensemble Health Partners provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act and applicable state and local law. If you require accommodation in the application process, please contact [email protected].

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