Second Level Reviewer I PRN Remote

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

• Reviews concurrent medical records for documentation compliance, ensuring 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 into CDI Software accurately and concisely, resulting in precise metrics obtained through the reconciliation process.
• Recognizes opportunities for documentation improvement using strong critical-thinking skills and sound judgment.
• 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, and nursing, with quarterly and annual compliance updates from Medicare.
• 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 cases, prioritizing resolution of those with clinical documentation clarifications.
• Participates in department meetings, providing feedback on outstanding issues, presentations for educational opportunities, and addressing needs identified by CDI leaders.
• Assumes personal responsibility for professional growth, development, and continuing education to maintain a high level of proficiency.
• Performs other duties as assigned.

Qualifications

• Bachelor's of Nursing [Required]
• Master's [Preferred]
• Field Of Study in healthcare related field
• 5+ years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
• 3+ years of Clinical Documentation Specialist experience [Required]
• 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.
• Registered Nurse (RN) [Required]
• Physician Assistant (PA) [Required]
• Advanced Practice Registered Nurse (APRN) [Required]
• Certified Clinical Documentation Specialist (CCDS) [Required]
• Certified Billing and Coding Specialist (CBCS) [Preferred]
• Certified Cardiac Device Specialist (CCDS) [Required]

Benefits

• All the benefits and perks 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, Whole Person Well-being Resources, Mental Health Resources and Support, Pet Benefits, Schedule PRN Shift Day (United States of America)

Pay

$31.82 - $59.17

Schedule

PRN Shift Day (United States of America)

Contact Information

Address: 900 HOPE WAY, Altamonte Springs, FL 32714