Clinical Documentation Integrity Specialist

About the role

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Responsibilities

• Facilitate and obtain quality physician documentation for clinical conditions and procedures to support the severity of illness, risk of mortality, and complexity of patient care.
• Educate members of the patient care team regarding documentation guidelines.
• Adequately adhere to departmental and organizational goals, standards of performance, and policies to ensure quality documentation and regulatory compliance.
• Collaborate with physicians, nursing, and HIM coders to achieve documentation integrity.
• Maintain respectful relationships and participate in outstanding customer service.
• Conduct well-timed follow-up case reviews on all concurrent cases, prioritizing those with clinical documentation clarifications.
• Participate in department meetings, providing feedback on outstanding issues and educational opportunities.
• Assist in new hire orientation through precepting and mentoring.
• Complete educational projects to be presented to CDI team at least once yearly.
• Function as a subject matter expert (SME) for CDI.
• Serve as a CDI department liaison to new physician on-boarding.
• Assist CDI Manager with auditing CDS accounts.
• Maintain CCDS credentialing.
• Assume responsibility for professional growth, development, and continuing education to maintain proficiency.
• Maintain a 97% physician response rate to all valid clarifications.
• Demonstrate competence by achieving an annual average of 95% on compliance audit scores.
• Education: Associates in nursing or health related field.
• Work Experience: 4+ acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience; 2+ clinical documentation specialist experience.

Qualifications

• Registered Nurse (RN)
• Physician Assistant (PA)
• Certified Registered Nurse Practitioner (CRNP)
• Advanced Practice Registered Nurse (APRN)
• Medical Doctor (MD)
• Doctor of Osteopathic Medicine (DO)
• Educational Commission for Foreign Medical Graduates (ECFMG)
• Certified Clinical Documentation Specialist (CCDS)

Skills and Abilities

• 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.

Additional Information

Candidate may be an unlicensed physician who graduated from a medical school listed in the World Directory of Medical Schools AND meets eligibility requirements to apply for the ECFMG Certification.

Physical Requirements

View physical requirements

Pay Range

$72,786.83 - $135,385.27