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Clinical Documentation Specialist

Company: Lee Health
Location: Fort Myers
Posted on: March 21, 2020

Job Description:

The role of the Quality Documentation/Clinical Documentation Improvement Specialist (CDIS) II, while incorporating the CDIS level I role, is expected to demonstrate a higher level of comprehension of the concurrent review process through knowledge and experience. The CDIS II is able to consistently recognize clinical indicators and use knowledge pertaining to nursing experience and deep knowledge of pathophysiology to obtain physician documentation that reflects accuracy in care and diagnoses in the patient''s record. The CDIS II is able to consistently identify opportunities to query for assignment of DRG, major co- morbidities (mcc) and simple co-morbidities (cc) when clinical evidence is present. The CDIS II query''s are consistent and obtain a high level of quality and complexity with clinical indicators when warranted. The query''s are diverse and pertain to all patient populations within the health system. Educational Requirements Degree/Diploma Obtained Program of Study Required/Preferred and/or Bachelor''s Required Bachelor''s Nursing Preferred Experience Requirements Minimum Years Required Area of Experience Required/Preferred and/or 2 Years CDI Required Additional Requirements Knowledge of coding guidelines and sequencing of diagnoses. Must be knowledgeable of business medicine and transitional healthcare changes. State of Florida Licensure Requirements Licenses Required/Preferred and/or Registered Nurse License Required Certifications/Registration Requirements Certificates/Registrations Required/Preferred and/or CCDS (Certified Clinical Documentation Specialist) Required Additional Requirements Current License as RN in the state of Florida. CCDS within 6 months of promotion, mandatoryby Jobble

Keywords: Lee Health, Fort Myers , Clinical Documentation Specialist, Healthcare , Fort Myers, Florida

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