Clinical Documentation Specialist

Clinical Documentation Specialist – Southeast Region

All the benefits and perks you need for you and your family:

Our Promise To You

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. All while understanding that together we are even better.

Schedule: 40 hour week (Exempt)

Shift: Days

Location: Remote

The Role You’ll Contribute

Under general supervision of the Director of Clinical Documentation Integrity and in some situations the supervision of the Clinical Documentation Integrity Manager, and in collaboration with physicians, nursing and HIM coders, the Clinical Documentation Specialist (CDS) strategically facilitates and obtains appropriate and quality physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The CDS educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, care management and etc… The CDS adheres to strict departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

Principal Duties And Job Responsibilities

• Demonstrates extending the healing ministry of Christ, through behavioral whole care standards of love me, make it easy, own it and keep me safe to every person they meet. Delivers exceptional care and strives for excellence. Committed to improving the health, prosperity and well-being of the communities we serve. Uphold the highest standards, with integrity driving every decision made and every action taken. Guided by relentless stewardship in the management of resources entrusted to them.
• Reviews concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM) and quality.
• Completes accurate and timely record review to ensure the integrity of documentation compliance. Completes accurate and concise input of data into CDI Software resulting in accurate metrics obtained through the reconciliation process. Understands and supports CDI documentation strategies
  
  

(upon completion of didactic training) and continues to educate self and team members, by attending monthly mandated education sessions and using educational tools, videos and provided Webinars

• Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping quality considerations in balance with regulatory compliance. Initiates/formulates CDI severity worksheets and clinically credible clarifications for inpatients, sending/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 is accomplished.
• Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, nursing, and collaboration with the healthcare team. This includes quarterly and annual compliance updates from Medicare.
• Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation. Communicates with HIM staff and collaborates with them to resolves discrepancies with DRG assignments and other coding issues.
• Completes well-timed follow-up case reviews on all concurrent cases with priority given for resolution of those with clinical documentation clarifications.
• Participates in department meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified by the CDI leaders.
• Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.
• Demonstrates competence in chart audits
• Correctly identifies physician clarification opportunities
• Proficient in formulating valid clarifications that are easily understood by physicians and other members of the medical team.
• Accurately reconciles all cases in CDI database.
• Maintains a 95% physician response rate to all valid clarifications.
• Performs other duties as assigned.
  
  

Qualifications

The expertise and experiences you’ll need to succeed:

Education And Experience Required

• Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
  
  

Education And Experience Preferred

• BSN or Higher
• Clinical Documentation Specialist experience
  
  

Licensure, Certification Or Registration Required

• Current active State license as one of the following:
• Registered Nurse in the state of Residence
• Nurse Practitioner
• Physician’s Assistant
• Unlicensed physician who is an MD in the United States or in their country of Origin and has graduated from a medical school that is listed in the World Directory of Medical Schools (World Directory) as meeting eligibility requirements for its graduates to apply to the Educational Commission for Foreign Medical Graduates (ECFMG) for ECFMG Certification and examination at the time of graduation.
  
  

Licensure, Certification Or Registration Preferred

• CCDS (Certified Clinical Documentation Specialist) certification
• CDIP (Certified Documentation Improvement Practitioner) certification
  
  

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.