Clinical Documentation Specialist

Halifax Health is seeking a Clinical Documentation Specialist for the HIM Department.

This individual is responsible for identifying opportunities in concurrent and retrospective Inpatient clinical medical documentation to support quality, regulatory compliance, and effective coding. The CDI Specialist reviews inpatient medical records while patients are still in house (concurrent review) for proper documentation. This review includes new admissions to the facility, as well as re-reviews every two to three days until the patients are discharged. The CDIS communicates with clinicians and physicians, acting as an effective change agent and educator for physicians and allied health staff.  The CDIS will also perform focused reviews at the discretion of the HIM Director or Coding Manager.

• Currently licensed as an RN in the State of Florida.
• Associate's or Bachelor's degree from an accredited School of Nursing. 
• A minimum of two years experience in nursing, utilization review/case management or other clinical area in an acute care facility.  
• Experience in or knowledge of ICD-10 inpatient coding, as well as an understanding of the requirements for clinical coding and billing and knowledge of medical necessity criteria preferred. 
• Good interpersonal, organizational, analytical and prioritization skills. 
• Effective written and verbal communications skills required.
• One to three years progressive ICD-10 and CPT coding of hospital inpatient medical records of various complexity or 2 years minimum Clinical nursing in an acute care setting with knowledge of ICD-10 coding. 
• Demonstrated ability to work independently with minimal supervision.
• Requires coding skills with experience with inpatient ICD-10-CM coding and working knowledge of the AHA "Coding Clinic," as well as a strong understanding of the requirements for clinical coding and billing, along with knowledge of medical necessity criteria.
• Effective interpersonal skills in order to interact effectively with all levels of hospital personnel. 
• Demonstrated ability to work independently, with minimal supervision. 
• Proficient computer skills, with the ability to use Word and Excel; software packages related to encoding and revenue. 

• Concurrent auditing of inpatient medical record documentation.
• Applies professional attitude and communication skills when consulting with physicians and clinical staff.
• Consults with physicians and clinical staff for clarification when conflicting information appears in the medical record documentation.
• Communicates and works well with Interdisciplinary Team to ensure accurate and complete medical record documentation is captured concurrently, promoting team success through successful working relationships.
• Maintains and reports clinical documentation improvement results in a clear and concise manner to the medical and clinical staff, as well as the Coding Manager and Director.
• Exhibits skillful, up to date working knowledge of all coding guidelines researching websites, trade journals, publications and reference materials.
• Applies critical thinking skills to appropriately react to opportunities for process improvement.
• Exhibits appropriate ethical standards by adhering to coding policies and guidelines published in the AHA "Coding Clinic."
• Adheres to coding policies and guidelines as well as HIM department policies and procedures.

Recognized as one of the 50 Top Cardiovascular Hospitals™ in the United States by IBM Watson Health™, Halifax Health serves Volusia and Flagler counties, providing a continuum of health care services through a network of organizations including a tertiary hospital, two community hospitals, urgent care clinics, psychiatric services, a cancer treatment center with five outreach locations, the area’s largest hospice, a center for inpatient rehabilitation, outpatient rehabilitation clinics, primary care walk-in clinics, a clinic specializing in women’s health, a pediatric care community clinic, five pediatric medical practices, a home health care agency and an exclusive provider organization. Halifax Health offers the area’s only Level II Trauma Center, Thrombectomy-Capable Stroke Center (TSC), Center for Transplant Services, Pediatric Intensive Care Unit, Child and Adolescent Behavioral Services, complete Neurosurgical Services, OB Emergency Department and Level III Neonatal Intensive Care Unit that cares for babies born earlier than 28 weeks. For more information, visit halifaxhealth.org.