Registered Nurse Clinical Documentation Specialist FT Days in Tavares, FL at Florida Hospital Waterman

Date Posted: 9/15/2018

Job Snapshot

  • Job Schedule
  • Location:
    Tavares, FL
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Function
    Case Management
  • Travel
  • Shift
    1 - Day
  • AHS Zone
    1-Shared Services
  • Organization
    Florida Hospital Waterman

Job Description

Work Hours/Shifts
Full Time Days.
Florida Hospital Waterman
Florida Hospital Waterman is a career destination for individuals who feel a calling to help fulfill our mission of providing whole-person care that is highly compassionate and clinically first-rate. Drawn by that mission, team members also appreciate our state-of-the-art hospital, which is strikingly situated on a lovely lakeside campus, approximately 1 hour Northwest of Orlando. In August 2003, the hospital opened the doors of this replacement facility on Hwy 441 in Tavares. The 450,000 square foot, 269-bed acute care facility offers the latest in medical technology. Each patient room is private, and the uniquely designed "clover leaf" patient care units consist of 60 beds per floor. The Emergency Department is sized to accommodate up to 60,000 visits per year.
Florida Hospital Waterman is committed to meeting our region's growing need for advanced comprehensive cardiac care. As part of that commitment, we are expanding our range of services to include interventional cardiology and open heart surgery services. At Florida Hospital Waterman, you'll enjoy a satisfying career and lifestyle as you help carry out our vital mission. We invite you to join our team!

You will be responsible for:

  • Performs accurate and timely review of electronic health record to initiate work sheets on DRG payers for inpatient admissions
  • Demonstrates the ability to analyze and identify areas of potential gaps representing opportunities for documentation improvement in order to reflect severity/complexity profile making an appropriate determination whether a physician clarification/query is required
  • Possess the ability to formulate clinically credible documentation/ clarifications/queries; utilizing effective and appropriate communication options for physician follow up, which will occur in a timely manner
  • Identifies the need and presence of “MCC” or “CC” for the DRG
  • Demonstrates efficiency in Guide (JATA) guidelines, software and accurate input of data into CDMP Trak.  As well as, the ability to review archived cases and generate reports as needed
  • Requires knowledge of Medicare Part A as well as regulatory requirements that will be demonstrated by appropriate assignment of principal diagnosis and surgical procedure(s)
  • Clinical reviews and concurrent code assignment performed by CDS will demonstrate understanding of requirements and guidelines in accordance with AHA (American Hospital Association) Coding Clinics
  • Possession of analytical based concepts, critical thinking, problem solving and deductive reasoning skills in regards to patient health assessment and disease entities shall be evidenced in achievement of optimum DRG assignment
  • Excellence of interpersonal and communication skills will be evidenced through interaction with HIM staff (coders) in resolution of discrepancies
  • Department improvement shall be demonstrated through participation in the development and implementation of plans for education of physicians, nursing and ancillary staff
  • Computer proficiency will be demonstrated and maintained to perform/complete work assignments including but not limited to the electronic medical record, Guide, Optum coding software, Internet Explorer, Microsoft Word/Power Point/Excel, Outlook email/calendar management
  • Assists with special projects as needed

What will you need?

  • R.N. – registered nurse
  • Minimum 5 years of recent hospital experience
  • State of Florida Registered Nursing License
  • BSN (preferred)
  • ICU, CCU, or strong Med/Surg. Experience (preferred)  
  • Utilization Review or coding experience (preferred)
  • BSN or MA (preferred)
  • CCDS – Certified clinical documentation specialist (preferred)
  • Knowledge of Pathophysiology and disease process
  • Working expertise in the use of Microsoft Word, Power-Point and Excel programs. 
  • Proficient typing skills with the ability to accurately type >35 words per minute.

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

Location | Organization | Category | Job Function