Clinical Document Specialist III

Texas Health Huguley FWS; Orlando (FL); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare provider is seeking a Clinical Document Specialist III in Orlando, Florida. This role involves collaborating with healthcare professionals to ensure quality documentation meets regulatory standards and supports the severity of illness and complexity of care. You will be part of a committed team with a focus on extending the healing ministry, alongside the attractive benefits including a sign-on bonus and flexible working hours.

Benefits

Benefits from Day One

Paid Days Off from Day One

Debt-free Education

Sign-on Bonus

Qualifications

• Minimum of five years acute care nursing experience.
• Current active State license as a Registered Nurse or equivalent.
• CCDS or CDIP certification required.

Responsibilities

• Facilitates and obtains quality physician documentation.
• Reviews medical records for compliance and accuracy.
• Initiates opportunities for documentation improvement.

Skills

Critical Thinking

Attention to Detail

Communication

Education

BSN

CCDS certification

CDIP certification

Job description

Job Description - Clinical Document Specialist III (25012782)

Job Description

Clinical Document Specialist III (

Job Number:

25012782 )

Description

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) for eligible positions

**7,500 Sign On Bonus

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 to Friday, 40 hrs - Fully Remote - Flexible hours may be between 6a-630pm

Shift: Full Time Days Salary Exempt

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 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 CDS educates members of the patient care team regarding documentation guidelines, including 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 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.

Qualifications

The expertise and experiences you’ll need to succeed: :

• Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
• BSN and three years of Clinical Documentation Specialist 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.
• CCDS (Certified Clinical Documentation Specialist) certification, in lieu of BSN and 3 years of experience or
• CDIP (Certified Documentation Improvement Practitioner) certification, in lieu of BSN and 3 years of experience