Florida Licensed Clinical Documentation Specialist

Job Summary

Providing concurrent review of clinical documentation, the full-time remote CDE II, RN will identify missing or understated diagnoses and procedures, coordinating with various departments to ensure accurate medical records that reflect patient acuity and level of care.

Key responsibilities

• Conduct initial and follow-up concurrent reviews of medical records to clarify documentation for accurate patient acuity reflection
• Collaborate with coding, HIM, and UR departments to ensure comprehensive and accurate documentation
• Educate providers on the importance of complete documentation and maintain productivity levels established by the department

Required qualifications

• Graduate from an approved school of nursing
• Current State of Florida RN license or valid eNLC multistate RN license
• Three years of acute care hospital nursing experience and one year of acute care CDE experience
• Thorough knowledge of ICD-9-CM, ICD-10-CM/PCS, APR DRG, and MS DRG
• Extensive clinical knowledge and understanding of pathology/physiology gained through clinical experience in a hospital setting