Clinical Document Specialist PRN

1103 Team Member Services; Daytona Beach (FL); On-site; USD 44,000 - 82,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

Paid Time Off from Day One

403-B Retirement Plan

4 Weeks Paid Parental Leave

Career Development

Whole Person Well-being Resources

Mental Health Resources and Support

Pet Benefits

Job summary

AdventHealth in Daytona Beach is seeking a Clinical Documentation Specialist to review and improve documentation for accuracy and compliance. The role focuses on severity of illness, risk of mortality, and data integrity, with timely chart reviews and data entry into our software systems.

You will collaborate with clinical teams to clarify and refine documentation processes. Ideal candidates bring nursing education, CDI know-how, and strong critical-thinking skills to support the patient care

Qualifications

• Excellent interpersonal and verbal/written communication skills.
• Organize and present information clearly; proficient with multiple software.
• Learn and perform Clinical Documentation Specialist duties.
• Dependable, self-motivated and pleasant.
• Strong critical-thinking, problem-solving and deductive-reasoning skills.
• Knowledge of pathophysiology, disease processes and treatments.
• Ability to prioritize and manage multiple tasks.
• Knowledge of clinical documentation requirements.
• Coding background preferred.
• Knowledge of quality guidelines preferred.

Responsibilities

• Review concurrent medical records for SOI, ROM, and quality.
• Complete accurate and timely record reviews for documentation integrity.
• Input data into software to yield precise metrics via reconciliation.
• Identify opportunities for documentation improvements with clinical teams.
• Initiate CDI severity worksheets and clarifications for inpatients.

Skills

Interpersonal skills

Communication

Computer skills

Critical thinking

Problem solving

Deductive reasoning

Organization

Prioritization

Pathophysiology knowledge

Clinical documentation requirements

Coding background

Education

Bachelor’s in Nursing

Master’s in Nursing

Field of Study: Health Admin/Public Health

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.

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.

Schedule & Location

Schedule: PRN Shift: Day (United States of America)

Address: 301 MEMORIAL MEDICAL PKWY City: DAYTONA BEACH State: Florida Postal Code: 32117

Benefits

• 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

Pay Range

Pay Range: $32.13 - $59.76

Physical Requirements

Physical Requirements: (Please click the link below to view work requirements) Physical Requirements - https://tinyurl.com/23km2677

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: https://info.flclearinghouse.com/

Equal Opportunity Statement

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

Mission Statement

Every day, our fellow team members show up to work, unified by one shared mission: Extending the Healing Ministry of Jesus Christ. As a faith-based health care organization, our story is one of hope as we strive to heal and restore the body, mind and spirit. Though our facilities are spread across the country, this unwavering belief binds us together. Across every office, exam and patient room, we’re committed to providing individualized, holistic care. This is our Christian mission, and it inspires us to help make communities healthier and happier.

Qualifications

• 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.

Education

• Education: Bachelor's of Nursing [Preferred]
• Education: 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

• 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]

Licenses and Certifications

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