Clinical Documentation 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.

Responsibilities

• Educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, and nursing staff.
• Communicates effectively with physicians and other healthcare providers to ensure appropriate, accurate, and complete clinical documentation.
• Collaborates with staff to resolve discrepancies with assignments and coding issues.
• Conducts well-timed follow-up case reviews on all concurrent cases, prioritizing those with clinical documentation clarifications.
• Participates in department meetings, providing feedback on outstanding issues and presenting educational opportunities.
• Maintains a 95% physician response rate to all valid clarifications.
• Reviews concurrent medical records for compliance, including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), and quality.
• Completes accurate and timely record reviews to ensure the integrity of documentation compliance.
• Inputs data accurately into CDI Software, resulting in precise metrics obtained through the reconciliation process.
• Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients, presenting opportunities for improved documentation compliance to clinical team members.
• Transcribes documentation clarifications as appropriate to ensure documentation compliance.
• Other duties as assigned.

Requirements

• 4+ years of acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience [Required]
• Clinical Documentation Specialist experience [Preferred]
• Associate’s degree in nursing or health-related field [Required]

Qualifications

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

Skills

• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations [Required]
• 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 [Required]
• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist [Required]
• Dependable, self-motivated, and pleasant [Required]
• Utilize and demonstrate excellent critical-thinking, problem-solving, and deductive-reasoning skills [Required]
• Knowledge of pathophysiology, disease processes, and treatments [Required]
• Strong ability to organize/triage work and manage multiple priorities at once [Required]
• Knowledge of clinical documentation requirements that identify clinical conditions or procedures [Preferred]
• Coding background [Preferred]
• Knowledge of quality guidelines [Preferred]

Benefits

• Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance
• Paid Time Off from Day One
• 403-B Retirement Plan
• 4 Weeks 100% Paid Parental Leave
• Career Development
• Whole Person Well-being Resources
• Mental Health Resources and Support
• Pet Benefits

Pay

$66,170.74 - $123,073.07

Schedule

• Full time
• Day shift

Location

1000 Waterman Way, Tavares, Florida, 32778, United States of America

Certain positions are subject to Florida Level 2 background screening, including fingerprinting, as required by state law.