Clinical Documentation Specialist III

About the role

Joining AdventHealth is about extending the healing ministry of Christ. This role is full-time, working Monday to Friday, 40 hours per week, with flexible hours between 6:00 a.m. – 6:30 p.m. The location is fully virtual.

Responsibilities

• Facilitate and obtain quality physician documentation for clinical conditions and procedures.
• 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.
• Provide education on documentation regulations and guidelines, including quarterly and annual Medicare updates.
• Collaborate with HIM staff to resolve discrepancies with DRG assignments and other coding issues.
• Communicate effectively with physicians and healthcare providers to ensure accurate and complete clinical documentation.
• Review concurrent medical records for compliance, completeness, and accuracy for severity of illness, risk of mortality, and quality.
• Complete accurate and timely record reviews to ensure documentation compliance.
• Input data into CDI Software accurately, resulting in precise metrics through the reconciliation process.
• Recognize opportunities for documentation improvement using strong critical-thinking skills.
• Initiate and formulate CDI severity worksheets and clinically credible clarifications for inpatients.
• Transcribe documentation clarifications for SOI, ROM, PSI, HCCs, and HACs to ensure compliance.
• Perform 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.

Qualifications

• Associates degree in nursing or health-related field.
• 4+ years of 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.

Skills

• 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 Skills

• Coding background.
• Knowledge of quality guidelines.

Education

• Associates degree in nursing or health-related field.

Licenses & Certifications

• 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

Pay Range

$72,786.83 - $135,385.27

Background Screening Requirement

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

Equal Opportunity Employer

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.