Clinical Document Specialist I

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)

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: FT

Shift : Days - Must have CDI Experience

The community you'll be caring for:

• Located on a lush tropical campus, our flagship hospital, 1,368-bed AdventHealth Orlando

• We offer great benefits with immediate Health Insurance coverage

• Career growth and advancement potential

• 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 Clinical Documentation Specialist (CDS) strategically facilitates and obtain 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 attending physicians, allied health practitioners, nursing, and care management.

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.

The value you'll bring to the team:

•Demonstrates, through behavior, Integrity, Compassion, Balance, Excellence, Stewardship, and Teamwork

•Reviews concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies.

•Completes accurate and timely record review to ensure the integrity of documentation compliance.

•Completes accurate and concise input of data into CDMP Trak resulting in accurate metrics provided by the CDMP program. Understands and supports CDMP documentation strategies (upon completion of training) and continues to educate self and team members using educational tools, videos and provided WebEx's.

•Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping reimbursement considerations in balance with regulatory compliance. Initiates/formulates CDMP severity worksheets and clinically credible clarifications for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other medical staff.

•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 attending physicians, allied health practitioners, nursing, and care management. This includes quarterly 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 Task Force meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified by the CDI group.

•Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.

•Performs other duties as assigned.

•Travels to different facilities of Advent Health on routine basis which could include overnight stay. Travel could be 30% of the time averaged over a calendar year.

KNOWLEDGE AND EXPERIENCE STRONGLY PREFERRED:

•Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrate 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

•Knowledge of regulatory environment

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

KNOWLEDGE AND EXPERIENCE PREFERRED:

•Knowledge of clinical documentation requirements that identify clinical conditions or procedures.

•Coding background

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.

•Clinical Documentation Specialist experience

EDUCATION AND EXPERIENCE PREFERRED:

•BSN, MSN

•Clinical Documentation Specialist experience

LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:

• Educational Commission for Foreign Medical Graduates

• Advanced RN Practitioner

• Physician Assistant

• Registered Nurse

LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:

•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.

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.

Category: Clinical/Medical Informatics

Organization: AdventHealth Orlando

Schedule: Full-time

Shift: 1 - Day

Req ID:

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.