RN CDI Specialist Full Time

Jupiter Medical Center • Full-time • Jupiter, Florida, United States • 5d ago

Ranked #1 for Safety, Quality and Patient Satisfaction, Jupiter Medical Center is the leading destination for world-class health care in Palm Beach County and the greater Treasure Coast.

Outstanding physicians, state-of-the-art facilities, innovative techniques and a commitment to serving the community enables Jupiter Medical Center to meet a broad range of patient needs. Jupiter Medical Center is the only hospital in Palm Beach, Martin, St. Lucie and Indian River counties to receive a 4-star quality and safety rating from the Centers for Medicare & Medicaid Services (CMS).

Education

Graduate of an accredited school of professional nursing, BSN preferred

Experience / Qualifications

Current RN licensure in the state of Florida
CCDS, CDIP, CCM, RHIA, preferred
Cerner, EPIC, & Claro (CDR2) software experience
Additional requirements per Department Policy
At least 2 yrs of acute care experience, critical care
2 years experience of clinical documentation

Position Summary

The clinical documentation specialist collaborates extensively with physicians, nursing staff, other patient caregivers and coding staff to improve the quality and completeness of documentation of care provided and coded for coordination, abstraction and submission of accurate data required by CMS.

Facilitates concurrent modifications to clinical documentation to ensure commensurate reimbursement of clinical severity and services rendered to patients with a Diagnosis Related Group based payer (Medicare, Medicaid).
Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes.
Communicates with and educates all physician and clinical staff concerning accurate and effective clinical documentation
Review concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI) and quality.
Reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. Translates diagnostic phrases utilized by healthcare providers into coded form; Interacts with the healthcare provider to ensure that the terms have been translated correctly.
Works collaboratively with physicians, other healthcare professionals and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate utilization, clinical severity, outcomes and quality is captured for the level of service rendered to all patients, as well as ensuring compliant reimbursement of patient care services.
Remains current of the continual changes in Federal and State regulations for prospective payment, keeps informed of changes in treatment modes and new procedures, and performs coding when physician documentation is vague or missing.
Assigns the appropriate DRG after concurrent review of the medical record.
Maintains awareness of the continual changes in Federal and State regulations for prospective payment.
Practices autonomously within professional nursing standards, the ANA Code of Ethics and the ANA Bill of Rights. Strives for quality outcomes and innovative practice in accordance with the Florida Nursing Practice Act and the Hospital/departmental policies. Ensures practice is in accordance with competency required for that area. This is done through participation in quality assurance or performance improvement initiatives. Provides services in a collaborative manner with other disciplines to ensure optimal and outcomes.
Performs other duties as assigned.

Team Member Competencies

Establishing Relationships

Builds effective networks, working relationships, and alliances in order to collaborate effectively within department and organization. Can relate to all kinds of people regardless of background; find topics and common interests that can be used to build rapport with others.

Peer Support

Provides guidance and feedback to help others strengthen knowledge/skills needed to accomplish tasks, solve problems, and perform effectively within the team.

Inspiring and Motivating Others

Fosters commitment and cohesiveness by facilitating cooperation and working as a team within the organization toward goal accomplishments. Work well with others, build consensus, and ensure cooperation to complete tasks and positive workflow.

Demonstrating Emotional Intelligence

Exercises self-leadership, self-awareness, and self-regulation; manages emotions so that they are expressed appropriately; leads others by showcasing adaptability, empathy, and social skills.

Acting with Integrity

Interacts with others in a way that is seen as direct and truthful; ensures confidence in individual and organizational motives and representations. Acts in a way that is consistent with personal and organizational values by keeping confidence, promises, and commitments. Clearly states goals and beliefs; informs people of their true intentions, does what they say they will do; follows through on commitments.

Being a Champion for Change and Innovation

Supports people in their efforts to try new things. Things creatively, generates novel and valuable ideas and uses these ideas to develop new or improved processes. Accepts new ways of doing things and adapts to change.

Communicating Effectively

Speaks and writes clearly, conveys information in a concise, organized, and logical manner. Is adept at tailoring the message to fit the interests and needs of the audience. Listens attentively and exercises tact, discretion, and diplomacy when interacting with members of the department and organization.

Promoting Diversity and Inclusion

Treats all people with dignity and respect. Demonstrates an open-minded approach to understanding people regardless of their gender, age, race, national origin, religion, ethnicity, disability status, or other characteristics. Challenges bias and intolerance. Develops all-inclusive groups in the realms of social interaction and communication. Shows respect for the beliefs of others; encourages and promotes practices that support cultural diversity; discourages behaviors or practices that may be perceived as unfair, biased, or critical toward people with certain backgrounds.

Physical Requirements

Requires sitting for long periods of time, also stooping, bending, standing, and stretching. Must have manual dexterity for typing and computer data entry. Able to work under a stressful environment, work independently, capable of making sound decisions, be detail oriented, alert, and self-motivated. Ability to push/pull up to 40lbs., carry and lift up to 20lbs.

Threshold Requirements

These threshold requirements are required and completed yearly basis
- Annual Joint Commission mandatory education requirements, in-service and health requirements including attendance at new employee orientation
- TB/PPD Surveillance Program
- Maintenance of required professional licensing and/or certification(s).

This is not necessarily an extensive list of all responsibilities, skills, duties, requirements, or working conditions associates with the job. While this is intended to be an accurate reflection of the current job, management reserves the right to revise the job or require that other or different tasks be performed when circumstances change (i.e. emergencies, changes in personnel, workload, rush jobs or technical developments). I have reviewed these job requirements and verify that I can perform all essential functions of this position.

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