Job Description

Day (United States of America)Registered Nurse- Clinical Documentation Integrity Specialist IThe Clinical Documentation Integrity Specialist I role is focused on reviewing medical records to identify documentation improvement opportunities and writing compliant physician queries. This position supports accurate clinical documentation by engaging providers, completing assigned education, and escalation of unresolved queries per policy. The CDIS I plays a key role in ensuring documentation integrity and quality while developing foundational CDI skills.

JOB QUALIFICATIONS:

• Currently licensed as an RN in the state of Florida
• Associate Degree in Nursing (ADN) required, Bachelor of Science in Nursing (BSN) preferred
• 3+ years of experience in an acute care setting, 5+ years of acute care experience preferred, critical care experience preferred
• Epic and Optum experience strongly preferred

DUTIES AND RESPONSIBILITIES:

• Conduct concurrent reviews of inpatient medical record documentation.
• Analyze clinical information to identify areas within the chart for potential gaps in physician documentation and correctly identify physician query opportunities
• Collaborate with physicians and clinical staff to clarify ambiguous or conflicting documentation through the query process.

• Collaborate with HIM coding staff to promote complete and accurate clinical documentation
• Work effectively with interdisciplinary teams to ensure accurate, timely, and complete medical record documentation.
• Maintain up to date knowledge of coding guidelines through continuous review of relevant resources.
• Apply critical thinking skills to identify opportunities for process improvement.
• Escalate no response queries to CDI Supervisor or CDI Team Lead according to query escalation policy
• Adhere to coding and departmental policies, procedures, and ethical standards.
• Other duties as assigned.

PHYSICAL DEMANDS: Stationary. Work postures consist of mostly sitting, with brief periods of walking or standing.

WORKING CONDITIONS: Office environment. Hybrid Role.

SPECIAL EQUIPMENT/WORK AIDES: Computer, multi-line telephone.