Overview:
The RN, Clinical Doc Integrity Specialist, ensures the accuracy, completeness, and regulatory compliance of clinical documentation. Collaborates with healthcare providers to enhance documentation quality and analyzing clinical records to identify discrepancies. Implements improvement initiatives, monitors adherence to policies, and educates clinical staff on best practices. Supports audits and quality assurance activities, reporting findings and recommending corrective actions to management for continuous improvement.
Responsibilities:
As the RN, CDIS the incumbent:
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Ensures accuracy, completeness, and regulatory compliance of clinical documentation.
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Collaborates with healthcare providers to enhance documentation quality.
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Analyzes clinical records to identify discrepancies and implement improvements.
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Monitors adherence to documentation policies and educates clinical staff.
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Supports audits and quality assurance activities.
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Reports findings and recommends corrective actions to management.
Qualifications:
Required Education:
Required Experience: 3+ years experience in clinical documentation improvement
- Knowledge of healthcare regulations and documentation standards
- Experience conducting audits and quality assurance activities
- Strong collaboration skills with clinical providers and coding teams
- Ability to develop and deliver staff education and training
Required license: Active State of Florida Nurse license
