Clinical Documentation Integrity Specialist Full Time Days

Position Summary

Under general supervision of the Clinical Documentation Integrity Program Manager, the Clinical Documentation Specialist II is responsible for improving overall quality and completeness of clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physician, case management, nursing staff, other patient caregivers and coding staff.  Ensures the accuracy and completeness of clinical information used for measuring and reporting physician outcomes.

EDUCATION

• Required:    Graduate of a foreign medical school or education recognized by the State of Florida as qualification for licensed Registered Nurse, LPN, Physician Assistant, or Advanced Practice Registered Nurse
• Desirable:   MBA, MPH, MHA or MSN 

EXPERIENCE

• Minimum of 2 years clinical or inpatient experience in an acute care setting required; 5 years strongly preferred.   

REQUIRED LICENSURE/REGISTRATION/CERTIFICATIONS

• Must be either: licensed in the State of Florida as a Registered Nurse, LPN, Physician Assistant or APRN licensed in the State of Florida or a graduate of a foreign medical school (with ECFMG Certification preferred but not required
• Certified in one of the following within 2 years of hire into the position: 
  • Certification in clinical documentation improvement through ACDIS or AHIMA (CCDS or CDIP) strongly desired.
  • Certified in coding (CCS) preferred.

OTHER QUALIFICATIONS

• Familiarity with coding concepts and coding software desired.
• Knowledge of care delivery documentation systems and related medical record documents.
• Knowledge of age-specific needs and the elements of disease processes and related procedures.
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Excellent written and verbal communication skills.
• Excellent critical thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff, and health information systems coding staff.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-sensitive environment.
• Computer literacy and familiarity with the operation of basic office equipment.
• Assertive personality traits to facilitate ongoing physician communication.
• Ability to stand and walk for periods of time is required in the performance of job responsibilities.
• Working knowledge of MS DRGs and national coding guidelines.
   

#LI-RS1

Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law. 

Who We Are
We are a community built on care. Our caregivers and supporting staff extend compassion to those in need, helping to improve the health and well-being of those we serve, and provide comfort and healing. Your community is our community.
Our Story
We started out as a small operation in California. In May 1969, we acquired four hospitals, some additional care facilities and real estate for the future development of hospitals. Over the years, we've grown tremendously in size, scope and capability, building a home in new markets over time, and curating those homes to provide a compassionate environment for those entrusting us with their care.
We have a rich history at Tenet. There are so many stories of compassionate care; so many "firsts" in terms of medical innovation; so many examples of enhancing healthcare delivery and shaping a business that is truly centered around patients and community need. Tenet and our predecessors have enabled us to touch many different elements of healthcare and make a difference in the lives of others.
Our Impact Today
Today, we are leading health system and services platform that continues to evolve in lockstep with community need. Tenet's operations include three businesses - our hospitals and physicians, USPI and Conifer Health Solutions.
Our impact spreads far and deep with 65 hospitals and approximately 510 outpatient centers and additional sites of care. We are differentiated by our top notch medi