JOB POSTING
RN, Clinical Doc Int Spec Lead| Clinical Documentation Improvement| Day | Full Time
The Villages, Florida
FULL_TIME |
Overview
Responsibilities
Qualifications
Leads in this position will lead the process in maintaining the accuracy and completeness of clinical documentation to support patient care and regulatory compliance. Reviews clinical records to identify gaps, collaborating with healthcare providers to enhance documentation quality, and developing improvement strategies and training programs. Monitors regulatory changes, leads audits and quality assurance activities, and facilitates communication between clinical teams and coding specialists. Reports findings and recommend corrective actions to uphold documentation standards and integrity.
Responsibilities
RN, Clinical Doc Int Spec Lead:
- Reviews clinical records to identify gaps and collaborates with providers to improve quality.
- Leads maintenance of clinical documentation accuracy and completeness.
- Develops improvement strategies and training programs.
- Monitors regulatory changes and leads audits and quality assurance.
- Facilitates communication between clinical teams and coding specialists.
- Reports findings and recommends corrective actions to uphold documentation standards.
Qualifications
Required Education: Diploma. Associate's degree in nursing; Preferred Bachelor's Deegree
License/Certification/Registration: Florida Registered Nursing or Advanced Practitioner - Florida Driver license required
Preferred: Certified Clinical Documentation Specialist (CCDS). Utilization Management, Case Management, Quality Improvement or Inpatient Coding experience preferred.
• 5+ years' experience leading clinical documentation improvement programs
• Expertise in regulatory compliance and audit management
• Proven ability to develop training programs and improvement strategies
• Strong skills in cross-functional team leadership and communication
• Experience monitoring documentation quality and reporting outcomes