Clinical Documentation Integrity Specialist II

About the role

Joining AdventHealth is about extending the healing ministry of Christ. As a Clinical Documentation Specialist, you will be part of a team dedicated to improving patient care through precise clinical documentation.

Responsibilities

• Inputs data into CDI Software accurately and concisely, resulting in precise metrics through the reconciliation process.
• 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, presenting opportunities for improved documentation compliance to physicians, nurse practitioners, and other clinical team members.
• Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs, and HACs to ensure documentation compliance.
• Educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, nursing, and collaboration with the healthcare team.
• Communicates effectively and appropriately with physicians and other healthcare providers to ensure accurate and complete clinical documentation.
• Collaborates with HIM staff to resolve discrepancies with DRG assignments and other coding issues.
• Completes well-timed follow-up case reviews on all concurrent cases, prioritizing resolution of those with clinical documentation clarifications.
• Participates in department meetings, providing feedback on outstanding issues, presentations for educational opportunities, and other needs identified by CDI leaders.
• Maintains a 98% physician response rate to all valid clarifications.
• Aids in new hire orientation through precepting and mentoring.
• Completes accurate and timely record reviews to ensure the integrity of documentation compliance.
• Reviews concurrent medical records for compliance, completeness, and accuracy regarding severity of illness, risk of mortality, and quality.
• Performs other duties as assigned.

Qualifications

• 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.
• Coding background.
• Knowledge of quality guidelines.
• 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+ years of clinical documentation specialist experience.

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.

• 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)

Physical Requirements

View physical requirements here

Pay Range

$66,999.24 - $124,618.59