Physicians Regional Healthcare System ยท 4 hours ago
Clinical Documentation Specialist
Naples, FL
Full-time
Onsite
Mid, Senior Level
4+ years expPhysicians Regional Healthcare System is seeking a Clinical Documentation Specialist (CDS) to enhance the quality and accuracy of patient records. The CDS will collaborate with healthcare providers to ensure that documentation reflects the patient's clinical status and supports regulatory compliance.
Health CareHospital
Responsibilities
Analyzes inpatient clinical records to identify opportunities for improving documentation accuracy, ensuring assigned codes reflect patient severity and acuity
Adheres to corporate recommended CDI workflows and uses CDI and medical records software, such as 3M 360 Encompass and Iodine Interact, to support documentation practices
Utilizes approved physician query processes to clarify documentation, ensuring queries are compliant, necessary, and non-leading, and follows up daily on unanswered queries
Conducts follow-up reviews of patient records to identify new documentation opportunities and ensures accuracy through continuous review
Tracks CDI activities within CDI software, accurately reporting impact metrics and maintaining clear records of all interactions and documentation efforts
Provides education and training to providers, explaining recommendations for documentation improvement and offering insights through individual or group sessions
Collaborates closely with coding professionals to ensure accurate diagnostic and procedural data through complete and compliant documentation
Leads physician education initiatives, developing strategies to improve documentation practices at the facility level and conducting formal training sessions
Monitors regulatory changes in coding, documentation, and quality metrics, ensuring compliance with updated standards and sharing information with staff as needed
Creates and submits accurate reports in a timely manner, maintaining up-to-date knowledge of best practices and industry standards to support CDI goals
Performs other duties as assigned
Maintains regular and reliable attendance
Complies with all policies and standards
Qualification
Required
Associate Degree in Nursing, or comparable clinical field (e.g., International MD)
4-6 years of acute care hospital nursing experience (e.g. medical/surgical unit, intensive care)
RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license (e.g., International MD)
Preferred
Bachelor's Degree in Nursing, Health Information Management, or a related field
3-5 years of experience in clinical documentation improvement, health information management, or inpatient coding
Experience in physician education or query processes
Familiarity with regulatory standards and quality metrics related to clinical documentation
CCS-Certified Coding Specialist or ICD-10 certification or trainer designation
Certified Clinical Documentation Specialist (CCDS)
RHIT - Registered Health Information Technician
RHIA - Registered Health Information Administrator
CDIP - Clinical Documentation Improvement Professional
Certified Coder-AHIMA or AAPC
Company
Physicians Regional Healthcare System
Why Physicians Regional Healthcare System? We are pleased you are considering a career with Physicians Regional Healthcare System.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
S
Scott Lowe
CEO
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