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    • RN Specialist - Pensacola - Baptist Health Care

    Baptist Health Care
    Baptist Health Care Pensacola

    1 day ago

    Default job background
    Full time
    Description

    Clinical Documentation Specialist- RN

    The Baptist Health Care Clinical Documentation Specialist- RN is responsible for ensuring accurate and comprehensive medical records. This role requires active participation in team meetings, education of staff, and review of medical records to ensure compliance with clinical documentation improvement strategies.

    Key Responsibilities:

    • Reviews medical records for completeness and accuracy, focusing on severity of illness (SOI) and quality.
    • Performs timely and accurate medical record reviews.
    • Identifies opportunities for documentation improvement and implements changes.
    • Develops and submits clinical documentation improvement severity worksheets for inpatients.
    • Formulates credible documentation clarifications and requests additional information as needed.
    • Follows up on cases requiring documentation clarification and ensures timely resolution.
    • Participates in task force meetings to discuss clinical documentation improvement strategies.
    • Communicates with HIM coding staff to resolve discrepancies and ensures accurate data entry into electronic clinical documentation improvement tools.
    • Maintains current knowledge and certifications in clinical documentation improvement strategies.

    Requirements:

    • Bachelor's Degree in Nursing or equivalent required.
    • 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU required.
    • Active Registered Nurse license in the State of Florida or eligible compact state required.

    Baptist Health Care is a leading healthcare provider committed to delivering exceptional patient care and improving community health. As a Clinical Documentation Specialist- RN, you will be part of a dynamic team dedicated to advancing clinical documentation practices and ensuring high-quality patient outcomes.

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