Spec Clin Doc Integrity | Day
uf health
Overview Provides clinically based concurrent and retrospective review of the hospital medical record to evaluate the documentation of the patient's acuity to support the medical care delivered. Facilitate appropriate physician documentation to accurately reflect a patient's severity of illness and risk of mortality. Provide tracking and trending of review data to perform ongoing physician education. Qualifications Required Education: Bachelor's Degree. Specific course work: Effective October 1, 2016 all employees hired or transferred into the position are required to have a Bachelor's degree in Nursing. (Current employees hired prior to October 1, 2016 will be grandfathered.) Preferred Education: MSN or PhD Necessary Skills: 1. Must have knowledge of clinical disease processes. Coding and reimbursement experience preferred. 2. Must have clinical experience in a facility setting. 3. Proficient in Access, Excel, Word and PowerPoint and the ability to independently produce documents or aptitude to develop this level of skill within a defined period of time. 4. Flexible, positive, clear interpersonal and communication skills with ability to facilitate the exchange of information within all hospital staff levels, including, but not limited to, physicians, hospital executives, and other professional and ancillary staff. 5. Analytical skills related to independently interpreting, preparing and analyzing data. 6. Knowledge of and ability to ensure and promote consistent, quality oriented, national leading practices, in all Clinical Documentation Improvement Projects. 7. Capacity to read, understand, interpret, implement and communicate governmental guidelines and compliance. Required Licensure/Certifications: Effective February 1, 2018 all employees hired or transferred into the position are required to be licensed to practice nursing in the state of Florida (Current employees hired prior to February 1, 2018 will be grandfathered.) -AND- Effective February 1, 2018, any employee who is hired or transferred into the position is required to have either certification below within four (4) years of hire or transfer. Once obtained, certification must be maintained. (Current employees hired prior to February 1, 2018 will be grandfathered.) -Certified Clinical Documentation Specialist (CCDS) certification -Certified Documentation Improvement Practitioner (CDIP) Required Experience: Minimum of 5 years of acute care nursing experience with at least 3 of those years being surgical intensive care or ICU clinical experience. Preferred Experience: Experience working with MSDRGs, APR DRGs and ICD-10 CM and PCS Able to educate and present to clinicians and physicians. Track, record, monitor and communicate Case Mix Index variables with physicians and other hospital departments. Preferred Licensure/Certifications: CCDS, CDIP, CCS, CCA
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