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.

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

• 4 Weeks 100% Paid Parental Leave

• Career Development

• Whole Person Well-being Resources

• Mental Health Resources and Support

• Pet Benefits

PRNShift:

Day (United States of America)Address:

900 HOPE WAYCity:

ALTAMONTE SPRINGSState:

FloridaPostal Code:

32714Job Description:

Reviews concurrent medical records for documentation compliance, including 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.Knowledge, Skills, and Abilities:

• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations. [Required]
• 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. [Required]
• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist. [Required]
• Dependable, self-motivated and pleasant. [Required]
• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills. [Required]
• Knowledge of pathophysiology, disease processes and treatments. [Required]
• Strong ability to organize/triage work and manage multiple priorities at once. [Required]
• Knowledge of clinical documentation requirements that identify clinical conditions or procedures. [Preferred]
• Coding background. [Preferred]
• Knowledge of quality guidelines. [Preferred]

Education:

• Bachelor's of Nursing [Required]
• Master's [Preferred]

Field of Study:

• in healthcare related field

Work Experience:

• 5+ years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience. [Required]
• 3+ years of Clinical Documentation Specialist experience [Required]

Additional Information:

• An 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.

Licenses and Certifications:

• Registered Nurse (RN) [Required] OR
• Physician Assistant (PA) [Required] OR
• Advanced Practice Registered Nurse (APRN) [Required] OR
• Certified Clinical Documentation Specialist (CCDS) [Required]
• Certified Billing and Coding Specialist (CBCS) [Preferred]
• Certified Cardiac Device Specialist (CCDS) [Required]

Physical Requirements: (Please click the link below to view work requirements)

Physical Requirements -

Pay Range:

$31.82 - $59.17

Background Screening Requirement (Florida Law)

Certain positions are subject to Florida Level 2 background screening, including fingerprinting, as required by state law.

Applicants may review general information about Florida’s background screening requirements at the Florida Care Provider Background Screening Clearinghouse:

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.