*POSITION SUMMARY * Clinical Documentation Specialists work with healthcare providers to ensure that clinical disease processes are properly documented reflecting the appropriate severity of illness and the level of service rendered to our patients. *PRIMARY ACCOUNTABILITES* 1. Provides CDI chart review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the condition and the acuity of care provided. 2. Conducts daily subsequent chart reviews communicating with providers regarding existing clarifications and or new documentation opportunities identified. 3. Demonstrates understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, and the ICD-10 CM and ICD-10 PCS coding system. 4. Must have working knowledge of insurance and payer issues relative to Clinical Documentation. 5. Drafts compliant queries as per regulatory guidelines. 6. Reconciliation of final coded cases reviewed to be performed daily. 7. Ensures effective utilization of technology to document, track and trend all CDI activity. 8. Acts as a mentor to new CDI associates assisting with onboarding and training. 9. Proactively develops a reciprocal relationship with the HIM Coding Professionals concurrently and retrospectively working through DRG mis matches. 10. Performs secondary chart reviews as needed for auditing and educational purposes. 11. Maintain departmental productivity standards. 12. Stays up to date with regulatory changes by completing all mandatory educational accountabilities in a timely manner. 13. Accurate and ethical time and attendance recording, ensuring all time reported outside of routine daily CDI operational time is approved by the CDI Manager. 14. Maintain and observe patient confidentiality as outlined in the National Patient Safety Goals and HIPAA guidelines always protecting the confidentiality of the health record and refusing to access protected health information not required for CDI-related activities. 15. Works in a respectful manner with all associates to develop communication and foster cooperative working relationships. *MINIMUM QUALIFICATIONS* ***Must live in Brevard County*** * Education: High School Diploma. * Licensure: N/A * Certification: RN or CCS or CIC or comparable. * Work Experience: 2 years Nursing or Inpatient Coding. * Knowledge/Skills/Abilities: o Proficient in Microsoft Office – Outlook, Word, Excel, PowerPoint. o Evidence of excellent oral and written communication and interpersonal skills. o Ability to work autonomously with minimal supervision. o Strong critical thinking skills. o Strong communication skills and professional presence. o Ability to maintain composure and professional demeanor. *PREFERRED QUALIFICATIONS* * Certification: RN or CCS or CIC with Clinical Documentation Certification (CDIP or CCDS). * Work Experience: 2 years Nursing or Inpatient Coding with 2 years Clinical Documentation experience. * Knowledge/Skills/Abilities: o Proficient in Microsoft Office – Outlook, Word, Excel, PowerPoint. o Evidence of excellent oral and written communication and interpersonal skills. o Ability to work autonomously with minimal supervision. o Strong critical thinking skills. o Strong communication skills and professional presence. o Ability to maintain composure and professional demeanor. *PHYSICAL REQUIREMENTS* * Majority of the time involves sitting or standing; occasional walking, bending, stooping. * Long periods of computer time or at workstation. * Light work that may include lifting or moving objects up to 20 pounds with or without assistance. * May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise. * Communicating with others to exchange information. * Visual acuity and hand-eye coordination to perform tasks. * Workspace may vary from open to confined, on site or remote. * May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle. *ABOUT HEALTH FIRST* At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve. **Job:** **Corporate Services* **Organization:** **Health First Shared Svcs Inc* **Title:** *Clinical Documentation Specialist- Coding and Documentation- * **Location:** *Florida - Brevard County-Melbourne* **Requisition ID:** *076594*