Clinical Documentation Specialist I

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

• Benefits from Day One
• Paid Days Off from Day One
• Student Loan Repayment Program
• Career Development
• Whole Person Wellbeing Resources
• Mental Health Resources and Support
• Pet Insurance*
• 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. Its 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: Full-Time / Shift : Day (Hybrid / 2-Day On-Site a week)

Locations: AdventHealth Apopka

The role youll 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 youll bring to the team:

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

Qualifications

The expertise and experiences youll need to succeed:

• Minimum of 5-years acute care nursing experience with specific Critical Care Setting: medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience
• Current active State license as a Registered Nurse, Nurse Practitioner, Physicians 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.
• 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.
• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist.

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 Apopka

Schedule: Full-time

Shift: 1 - Day

Req ID: 23047829

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.