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Clinical Documentation Specialist

Expired Job

Boca Raton Regional Hospital Boca Raton , FL 33427

Posted 5 months ago

Position Summary:

The Clinical Documentation Specialist facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of service rendered to all inpatients.

Position Expectations and

  • Facilitation of modifications to clinical documentation to support accuracy in documentation of medical conditions being monitored and treated during in the inpatient stay

  • Communication with the individual physicians and medical staff to facilitate complete and accurate documentation of the inpatient record.

  • Demonstration of knowledge of DRG payer issues, documentation opportunities and coding guidelines

  • Ensure the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.

  • Provision of education to the medical staff and the healthcare team regarding clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies

  • Conduct follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart.

  • Maintain thorough and current knowledge of clinical care and treatment of assigned patient populations to critically assess appropriateness of documentation.

  • Gather and analyze information pertinent to the documentation process, findings and outcomes in compliance with coding and regulatory guidelines

Knowledge/Special Skills:

  • Clinical expert with at least 2 years' recent inpatient experience

  • Professional, team player, able to communication well with others. Strong interpersonal skills, pleasing personality, positive

  • Good critical thinking skills, able to assess, evaluate, and teach

  • Excellent verbal and written communication skills

  • Proficiency in organization and planning

  • Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching

  • Understanding of organizational policies and procedures

  • Working knowledge of quality improvement theory and practice

  • Ability and willingness to seek out and accept change

  • Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice

  • Knowledge of federal, state and private payer regulations

Job Functions:

  • Communicate with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients.

  • Utilizes the hospital's designated clinical documentation system to identify opportunities for physician and hospital outcomes.

  • Provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a liaison to coders when additional information or documentation is needed to assign the correct DRG.

  • Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team in accordance with the hospital's designated clinical documentation system.

  • Gather and analyze information pertinent to documentation findings and outcomes

  • Contribute to a positive working environment and performs other duties as assigned or directed to enhance the overall efforts of the organization

  • Develop physician education strategies to promote complete and accurate clinical documentation and correct negative trends

  • Identify patterns, trends variances and opportunities to improve documentation review and process

  • Research literature to identify new methods development and overall documentation enhancement

  • Assist in the development and reporting of performance measures to the medical staff and other departments and prepare physician specific data information


  • Active participation on departmental and hospital committees and assigned Task Force groups

  • Comply with HIPAA (Health Insurance Portability and Accountability Act of 1996)

and Code of Conduct policies

  • Maintain interaction with appropriate resources that support growth and education of the CDI Team

Minimum Education and/or Experience Required:

  • Bachelor's degree required; BSN Preferred

  • Five or more years hospital coding and/or clinical documentation improvement experience


  • Five or more years of inpatient clinical experience. Advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting
  • RHIA/RHIT with ten years inpatient coding experience and documented education in anatomy/physiology and pharmacology


  • Current Florida RN license


  • Certified Coding Specialist (CCS).

  • Incumbent may be required to perform emergency duty before, during and/or beyond normal work hours or days in the event of an emergency, crisis situation or disaster (man-made or natural) including evacuation sites.

  • The person in this position will work in a smoke-free location, and is expected to adhere to all smoking restrictions.

  • In the spirit of wellness for both our employees and patients, Boca Raton Regional Hospital has instituted a mandatory influenza prevention vaccination program. Current employees must receive the influenza prevention vaccination free of charge during the recognized flu season. As a condition of employment, new hires will be required to comply with all program rules. This is a mandatory program with the exception of documented medical or religious reasons for not receiving the vaccine. For further information on this progressive program, please contact Boca Raton Regional Hospital's Human Resources Department at 561-955-4075.

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Clinical Documentation Specialist

Expired Job

Boca Raton Regional Hospital