Second Level Reviewer I

About the role

Joining AdventHealth is about extending the healing ministry of Christ. As a Clinical Documentation Specialist, you will be part of a community dedicated to the wholeness of each person, serving to uplift them in body, mind, and spirit.

Responsibilities

• Recognizes opportunities for documentation improvement using strong critical-thinking skills and formulates clinically credible clarifications for inpatients.
• Transcribes documentation clarifications as appropriate to ensure documentation compliance.
• 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 health information management staff to resolve discrepancies with diagnostic assignments and other coding issues.
• Completes well-timed follow-up case reviews on all cases, prioritizing those with clinical documentation clarifications.
• Participates in department meetings, providing feedback on outstanding issues and presenting educational opportunities.
• Assumes personal responsibility for professional growth, development, and continuing education to maintain a high level of proficiency.
• Affords assistance in new hire orientation through precepting and mentoring.
• Maintains regional productivity standards and demonstrates competence on compliance audit scores.
• Maintains a 97% physician response rate to all valid clarifications.
• Annually participates in Advanced Practice call.
• Maintains CCDS credentialing.
• Reviews concurrent medical records for documentation compliance, including completeness, accuracy and quality.
• Inputs data accurately and concisely into assigned software, resulting in accurate metrics obtained through the reconciliation process.

Requirements

• Knowledge of clinical documentation requirements that identify clinical conditions or procedures.
• Coding background.
• Knowledge of quality guidelines.
• Education: Bachelor's of Nursing [Required], Master's [Preferred] in healthcare related field.
• Work Experience: 5+ years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience [Required], 3+ years of Clinical Documentation Specialist experience [Required].
• Licenses and Certifications: Registered Nurse (RN) [Required], Adult Acute Care Nurse Practitioner (ACNPC) [Required], Physician Assistant (PA) [Required], Certified Clinical Documentation Specialist (CCDS) [Required], Certified Documentation Improvement Practitioner (CDIP) [Required], Certified Coding Specialist (CCS) [Preferred].

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.
• Strong ability to organize/triage work and manage multiple priorities at once.

Skills

• Knowledge of pathophysiology, disease processes and treatments.
• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills.

Benefits

Explore all the benefits you need for you and your family:

• 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

Schedule

Full time

Shift: Day

Pay

$66,170.74 - $123,073.07

Physical Requirements

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Additional Information

An equivalent combination of education and relevant work experience may be considered in lieu of the stated degree requirement:

• BSN and 3+ years of Clinical Documentation Specialist experience OR
• 4+ years of Clinical Documentation Specialist experience OR
• Less than 2 years of Clinical Documentation Integrity experience and 10 years of acute care nursing experience.

Equal Opportunity Employer

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