RN - Clinical Documentation Improvement Specialist (CDI) Full Time

Ranked #1 for Safety, Quality and Patient Satisfaction, Jupiter Medical Center is the leading destination for world-class health care in Palm Beach County and the greater Treasure Coast.

Outstanding physicians, state-of-the-art facilities, innovative techniques and a commitment to serving the community enables Jupiter Medical Center to meet a broad range of patient needs.

Jupiter Medical Center is the only hospital in Palm Beach, Martin, St. Lucie and Indian River counties to receive a 4-star quality and safety rating from the Centers for Medicare & Medicaid Services (CMS).

Education

Graduate of an accredited school of professional nursing, BSN preferred

Experience / Qualifications

• Current RN licensure in the state of Florida
• CCDS, CDIP, CCM, RHIA, preferred
• Cerner & Claro (CDR2) software experience
• Additional requirements per Department Policy
• At least 2 yrs of acute care experience, preferably critical care
• 2 years experience of clinical documentation preferred

Position Summary

The clinical documentation specialist collaborates extensively with physicians, nursing staff, other patient caregivers and coding staff to improve the quality and completeness of documentation of care provided and coded for coordination, abstraction and submission of accurate data required by CMS.

• Facilitates concurrent modifications to clinical documentation to ensure commensurate reimbursement of clinical severity and services rendered to patients with a Diagnosis Related Group based payer (Medicare, Medicaid).
• Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes.
• Communicates with and educates all physician and clinical staff concerning accurate and effective clinical documentation
• Review concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI) and quality.
• Reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. Translates diagnostic phrases utilized by healthcare providers into coded form;

Interacts with the healthcare provider to ensure that the terms have been translated correctly.

• Works collaboratively with physicians, other healthcare professionals and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate utilization, clinical severity, outcomes and quality is captured for the level of service rendered to all patients, as well as ensuring compliant reimbursement of patient care services.
• Remains current of the continual changes in Federal and State regulations for prospective payment, keeps informed of changes in treatment modes and new procedures, and performs coding when physician documentation is vague or missing.
• Assigns the appropriate DRG after concurrent review of the medical record.
• Maintains awareness of the continual changes in Federal and State regulations for prospective payment.
• Practices autonomously within professional nursing standards, the ANA Code of Ethics and the ANA Bill of Rights. Strives for quality outcomes and innovative practice in accordance with the Florida Nursing Practice Act and the Hospital / departmental policies.

Ensures practice is in accordance with competency required for that area. This is done through participation in quality assurance or performance improvement initiatives.

Provides services in a collaborative manner with other disciplines to ensure optimal and outcomes.

• Performs other duties as assigned.
12 days ago