All the benefits and perks you need for you and your family:
- Benefits from Day One
- Paid Days Off from Day One
- Debt-free Education (Certifications and Degrees without out-of-pocket tuition expense)
- Career Development
- Whole Person Wellbeing Resources
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: Monday through Friday 8a-5pm, no weekends, no travel. Fully Remote
Shift : Days Full Time Remote
Location : Remote to support Central Florida Facilities/Campuses
The community you’ll be caring for:
- Located on a lush tropical campus, our flagship hospital, 1,368-bed AdventHealth Orlando
- Serves as the major tertiary facility for much of the Southeast, the Caribbean and South America
- AdventHealth Orlando houses one of the largest Emergency Departments and largest cardiac catheterization labs in the country
- We are already one of the busiest hospitals in the nation, providing service excellence to more than 32,000 inpatients and 125,000 outpatients each year.
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 Second Level Reviewer I 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 Second Level Reviewer I educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and care management. The Second Level Reviewer I 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.
The value you’ll bring to the team:
Reviews concurrent medical record for documentation 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.
Maintains a 97% physician response rate to all valid clarifications.
Annual participation in Advanced Practice call.
Maintains CCDS credentialing
Qualifications
The expertise and experiences you’ll need to succeed :
Five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
BSN and 3 years of Clinical Documentation Specialist experience OR
4 years of recent Clinical Documentation Specialist experience OR
Less than 2 years of Clinical Documentation Integrity experience and 10 years of acute care nursing experience
Current active State license as a Registered Nurse, Nurse Practitioner, Physician’s Assistant or an unlicensed physician who 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 and
CCDS (Certified Clinical Documentation Specialist) certification or CDIP (Certified Documentation Improvement Practitioner) certification and 2 years of Clinical Documentation Integrity experience
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.
Category: Health Information Management
Organization: AdventHealth Orlando
Schedule: Full-time
Shift: 1 – Day
Req ID: 24039555
We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.