Clinical Documentation Specialist

Leesburg, FL US

Job ID: 2643 Position Type: HIM

National Hospital System is seeking Clinical Documentation Specialist to join their Team!

Beautiful Central Florida offers natural outdoor activities, friendly, family oriented communities and low cost of living!


Clinical Documentation Specialist Job Description:

Implements clinical documentation improvement activities in an effort to support accuracy and quality of the patient records at facilities and to ensure that coded diagnoses are an accurate reflection of the patient’s clinical status and care. The role of the CDI specialist involves reviewing the medical record documentation and clinical indicators and working with providers to ensure a complete and accurate medical record. An accurate medical record is important for the patient, for continuity of care by the next provider, and to demonstrate high quality care by the physician and the hospital. The CDI Specialist will identify potential gaps in clinical documentation for inpatient and payer populations as directed throughout the hospitalization. He/she will also educate physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.


Clinical Documentation Specialist Qualifications:

  • BSN, RN, or comparable clinical degree. English is required for both verbal and written communication
  • Must possess at least five years of acute hospital nursing experience (e.g. medical/surgical unit, intensive care). Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management and/or inpatient coding considered a plus.
  • ICU/Critical Care experience strongly desired
  • Prior experience in clinical documentation improvement, ICD coding and MS-DRGs preferred.
  • Prior experience educating physicians/providers preferred
  • Previous experience working in a clinical documentation improvement department or as a consultant strongly encouraged
  • Minimum of one-year auditing experience strongly encouraged
  • This individual must possess a comprehensive knowledge of medical terminology, disease processes and clinical competency.
  • Candidate must possess excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills.
  • Strong critical thinking skills and ability to integrate knowledge is necessary.
  • Prioritization and organizational skills required.
  • Must exhibit the ability to educate members of the healthcare team about clinical documentation.
  • Individual must demonstrate data quality and integrity skills.
  • At least one of the following is required: BSN, RN, or comparable clinical degree.
  • In addition, the following are highly desired: RHIT, RHIA, CDIP, CCDS, CCS and ICD-10 certification or designation.


Clinical Documentation Specialist Benefit Package:

  • Competitive Compensation
  • Generous Vacation & Holiday Plans
  • Medical, Dental & Vision
  • Flex Spending Accounts
  • Life Insurance
  • 401(k) Savings Plan
  • Disability & Critical Illness Insurance


For more information, please contact:

Lilliana del Real

954-492-4672


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