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Clinical Documentation Specialist (Full-Time) at Nemours

Posted in Construction 30+ days ago.

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Type: Full-Time
Location: Orlando, Florida

Job Description:

As one of the nation’s leading pediatric health care systems, Nemours is committed to providing all children with their best chance to grow up healthy. We offer integrated, family-centered care to more than 300,000 children each year in our pediatric hospitals, specialty clinics and primary care practices in Delaware, Florida, Maryland, New Jersey and Pennsylvania. Nemours strives to ensure a healthier tomorrow for all children – even those who may never enter our doors – through our world-changing research, education and advocacy efforts. At Nemours, our Associates help us deliver on the promise we make to every family we have the privilege of serving: to treat their child as if they were our own. 

Nemours is seeking a Clinical Documentation Specialist (Full-Time) to join our Nemours Children's Hospital team in Orlando, Florida.

Located in Orlando, Fla., Nemours Children’s Hospital is the newest addition to the Nemours integrated healthcare system. Our 100-bed pediatric hospital also features the area’s only 24-hour Emergency Department designed just for kids as well as outpatient pediatric clinics including several specialties previously unavailable in the region. A hospital designed by families for families, Nemours Children’s Hospital blends the healing power of nature with the latest in healthcare innovation to deliver world-class care to the children of Central Florida and beyond. In keeping with our goal of bringing Nemours care into the communities we serve, we also provide specialty outpatient care in several clinics located throughout the region.

Job Duties

This position reviews  inpatient medical records throughout hospitalization, analysis of clinical status of patient in reference to ICD10 coding and ascertains potential gaps in clinical documentation; attends clinical rounds and communication with attending physicians, consultants and residents to validate specific documentation and co-morbidities, which reflect the true representation of the patient’s clinical status and care.


  • Reviews inpatient records throughout the hospitalization – assessing orders, patient class, current treatment plan and documentation recorded for “gaps” in vermicular when compared to treatment plans and the documentation in the record.

  • Demonstrates and applies knowledge of AHA’s Inpatient Coding rules (i.e. Coding Clinic) and serves as expert in clinical documentation knowledge to Coder II (inpatient coder) with collaborative process on querying clinical staff.

  • Identifies patients appropriate for the Hospital Quality Measures, and prompts physician, RN, and ancillary clinical support for clinical documentation according to the accepted standards.

  • Identifies trends and/or opportunities to improve clinical documentation; presenting opportunities in addition, potential solutions to the HIM management team.

  • Uses expert knowledge of software tools to appropriately query physicians for documentation.

  • Extensive knowledge of medical terminology, anatomy, physiology, pharmacology and disease processes.

  • Reports trends or gaps in missed charge capture to Senior Manager, Hospital Coding and Billing.

Job Requirements


  • Bachelor's Degree required. Preferred Undergraduate Course of Study:  Health Information, and/or Nursing.

  • Minimum of five (5) years' experience required.

  • RN, RHIA, or CCS required.

  • AHIMA credential CDIP preferred.

  • Ability to provide independent and critical thinking regarding data analysis.

  • Ability to execute quantitative analysis using Crystal Reporting and Excel.

Our dedication to professionals who are dedicated to children frequently earns Nemours a spot on the list of top workplaces in the communities we serve. Our Associates enjoy comprehensive benefits, including our unique “Bridge to a Healthy Future” pediatric health plan, an integrated wellness program, opportunities for professional growth, and much more. As an equal opportunity employer, Nemours focuses on the best-qualified applicants for our openings.