Florida Licensed Clinical Documentation Specialist

Job Summary

To enhance clinical documentation quality, the full-time Florida Licensed Clinical Documentation Specialist will conduct concurrent and retrospective reviews of inpatient medical records, ensuring accurate documentation and compliance while working remotely.

Key responsibilities

• Facilitates appropriate physician documentation to accurately reflect patient severity of illness and risk of mortality
• Reviews medical records to identify gaps in clinical documentation and performs initial and concurrent reviews as required
• Communicates with physicians and healthcare providers to resolve documentation discrepancies and ensure completeness

Required qualifications

• Bachelor's degree in Nursing, Health Information Management, or a related medical field; graduate foreign medical degree considered
• Current RN, MD, or RHIA certification required; CCDS or CDIP certification preferred (must obtain within 3 years of hire)
• At least two years of direct patient care in an acute care setting or three years of inpatient coding experience required
• Proficiency with Microsoft Office and technology/software; experience with 3M 360 Encompass preferred
• Demonstrated extensive clinical knowledge and critical-thinking skills related to disease processes and management