Clinical Doc Specialist

AdventHealth; Denver (CO); On-site; USD 50,000 - 92,000; Full time

Benefits offered by this job

Medical, dental, vision

Life Insurance

Disability Insurance

PTO from Day One

Retirement plan 403(b)

Parental leave

Career development

Well-being resources

Mental health resources

Pet benefits

Job summary

AdventHealth in Denver, Colorado is seeking a Clinical Documentation Specialist to review and improve inpatient documentation for SOI, ROM, and quality. You will collaborate with physicians and care teams to ensure complete and accurate charting, while maintaining timely clarifications and high physician response rates.

Ideal candidates have RN licensure with CDI experience, strong critical thinking, and knowledge of regulatory guidelines.

Qualifications

• Bachelor's prepared RN with CDI focus.
• Clinical Documentation Specialist experience preferred.
• Knowledge of documentation regulations and guidelines.

Responsibilities

• Reviews concurrent medical records for SOI, ROM, and quality.
• Inputs data accurately into software for metrics.
• Educates care team on documentation requirements.
• Communicates with physicians to ensure complete documentation.
• Maintains 95% physician response rate to clarifications.

Skills

Interpersonal skills

Communication

Critical thinking

Documentation standards

Physician relations

Problem solving

Prioritization

Team collaboration

Knowledge of pathophysiology

Clinical documentation

Education

Bachelor's of Nursing

Master's of Nursing

Job description

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

Schedule:

Full time

Shift:

Day (United States of America)

Address:

2525 S DOWNING ST

City:

DENVER

State:

Colorado

Postal Code:

80210

Job Description:

• Reviews concurrent medical records for compliance, completeness, and accuracy regarding 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 accurately into software, resulting in precise metrics obtained through the reconciliation process.
• Recognizes opportunities for documentation improvement using strong critical-thinking skills.
• Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients, presenting opportunities for improved documentation compliance to clinical team members.
• Transcribes documentation clarifications as appropriate to ensure documentation compliance.
• Educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, and nursing staff.
• Communicates effectively with physicians and other healthcare providers to ensure appropriate, accurate, and complete clinical documentation.
• Collaborates with staff to resolve discrepancies with assignments and other coding issues. Conducts well-timed follow-up case reviews on all concurrent cases, prioritizing those with clinical documentation clarifications.
• Participates in department meetings, providing feedback on outstanding issues and presenting educational opportunities. Assumes personal responsibility for professional growth, development, and continuing education to maintain a high level of proficiency.
• Maintains a 95% physician response rate to all valid clarifications.
• 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 [Preferred]
• Master's of Nursing [Preferred]

Field of Study:

completed in health service administration, business administration, system performance engineering, industrial engineering, or public health

Work Experience:

• 5+ acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience. [Required]
• Clinical Documentation Specialist experience [Preferred]

Additional Information:

• N/A

Licenses and Certifications:

• Adult Acute Care Nurse Practitioner (ACNPC) [Required] OR
• Registered Nurse (RN) [Required] OR
• Advanced Practice Registered Nurse (APRN) [Required] OR
• Educational Commission for Foreign Medical Graduates (ECFMG) [Required]
• Certified Clinical Documentation Specialist (CCDS) [Preferred]

Physical Requirements:

Physical Requirements - https://tinyurl.com/23km2677

Pay Range:

$36.08 - $67.11

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