Clinical Doc Specialist II NE Full Time Days

About the role

Joining AdventHealth is about extending the healing ministry of Christ. This role involves reviewing medical records for compliance, completeness, and accuracy, supporting CDI documentation strategies, and educating patient-care team members about documentation regulations and guidelines.

Responsibilities

• Reviews concurrent medical records for compliance, completeness, and accuracy for severity of illness (SOI), risk of mortality (ROM), and quality.
• Completes accurate and timely record reviews to ensure documentation compliance.
• Inputs data into CDI Software accurately and concisely, resulting in precise metrics.
• Understands and supports CDI documentation strategies and continues self-education through monthly mandated sessions and educational tools.
• Recognizes opportunities for documentation improvement using strong critical-thinking skills.
• Uses critical thinking and sound judgment in decision-making, balancing quality considerations with regulatory compliance.
• Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients.
• Presents opportunities for improved documentation compliance to physicians, nurse practitioners, and other clinical team members.
• Transcribes documentation clarifications as needed.
• Ensures compliance for SOI, ROM, PSI, HCCs, and HACs.
• Edits patient-care team members about documentation regulations and guidelines, including Medicare updates.
• Communicates with healthcare providers to ensure accurate clinical documentation.
• Maintains a 97% physician response rate to all valid clarifications.
• Assists in new hire orientation through precepting and mentoring.
• Completion of educational project to be presented to CDI team yearly.
• Other duties as assigned.

Requirements

• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations.
• Able to organize and present information clearly and concisely; excellent computer and keyboarding skills; ability to use multiple software programs simultaneously; high degree of prioritization skills.
• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist.
• Dependable, self-motivated and pleasant.
• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills.
• Knowledge of pathophysiology, disease processes and treatments.
• Strong ability to organize/triage work and manage multiple priorities at once.
• Knowledge of clinical documentation requirements that identify clinical conditions or procedures.

Preferred

• Coding background.
• Knowledge of quality guidelines.

Education

Master's of Nursing [Preferred] Field Of Study MSN or higher degree in a healthcare related field

Work Experience

• 3+ years acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit [Required]
• 3+ years of clinical documentation specialist experience [Preferred]
• Emergency Department experience [Required]
• One year of Clinical Documentation Specialist experience. [Required]

Additional Information

N/A

Licenses And Certifications

• Registered Nurse (RN) [Required]
• Certified Registered Nurse Practitioner (CRNP) [Required]
• Certified Clinical Documentation Specialist (CCDS) [Preferred]
• Certified Cardiac Device Specialist (CCDS) [Preferred]

Physical Requirements

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Pay Range

$38.54 - $71.69