Clinical Documentation Integrity Specialist

adventhealth; Minneola (FL); On-site; USD 72,787 - 135,385; Full time

Benefits offered by this job

Medical, Dental, Vision 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 summary

AdventHealth in Florida is seeking a Clinical Documentation Specialist to improve documentation quality and support severity of illness and mortality risk. You will work with physicians, nurses, and HIM coders to ensure documentation integrity and educate teams on guidelines.

The role requires 4+ acute care nursing experience, 2+ CDI experience, and CCDS certification, with full-time day shift benefits from day one and ongoing professional growth opportunities.

Qualifications

• Associates degree required.
• 4+ acute care nursing experience with medical/surgical, ICU, post-acute, or ED experience.
• 2+ clinical documentation specialist experience.
• RN/PA/CRNP/MD/DO/ECFMG eligible with CCDS certification required.

Responsibilities

• Maintain a high physician response rate to clarifications (goal 97%).
• Collaborate with physicians, nursing, and HIM coders to ensure documentation integrity.
• Educate patient-care teams on documentation regulations and Medicare updates.

Skills

Interpersonal communication

Documentation standards

Critical thinking

Physician relations

Multi-software literacy

Time management

Education

Associates

Field of Study: nursing or health related field

Tools

CDI Software

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 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:

1800 N HANCOCK RD

City:

MINNEOLA

State:

Florida

Postal Code:

34715

Job Description:

Responsible for facilitating and obtaining quality physician documentation for clinical conditions and procedures to support the severity of illness, risk of mortality, and complexity of patient care. This position educates members of the patient care team regarding documentation guidelines. Additionally, this role adheres to departmental and organizational goals, standards of performance, and policies to ensure quality documentation and regulatory compliance. In addition, this position collaborates with physicians, nursing, and HIM coders to achieve documentation integrity. Responsibilities for this role include maintaining respectful relationships and participating in outstanding customer service.

• 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 educational opportunities.
• Assists in new hire orientation through precepting and mentoring.
• Completion of educational project to be presented to CDI team at least once yearly.
• Functions as a subject matter expert (SME) for CDI.
• Serves as a CDI department liaison to new physician on-boarding.
• Assists CDI Manager with auditing CDS accounts. Maintains CCDS credentialing.
• Assumes responsibility for professional growth, development, and continuing education to maintain proficiency.
• Maintains a 97% physician response rate to all valid clarifications.
• Demonstrates competence by achieving an annual average of 95% on compliance audit scores Educates patient-care team members on documentation regulations and guidelines, including quarterly and annual Medicare updates.
• Collaborates with HIM staff to resolve discrepancies with DRG assignments and other coding issues.
• Communicates effectively with physicians and healthcare providers to ensure accurate and complete clinical documentation.
• Reviews concurrent medical records for compliance, completeness, and accuracy for severity of illness, risk of mortality, and quality.
• Completes accurate and timely record reviews to ensure documentation compliance.
• Inputs data into CDI Software accurately, resulting in precise metrics 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.
• Transcribes documentation clarifications for SOI, ROM, PSI, HCCs, and HACs to ensure compliance.
• 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:

• Associates [Required]

Field of Study:

• in nursing or health related field

Work Experience:

• 4+ acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience [Required]
• 2+ clinical documentation specialist experience [Required]

Additional Information:

• Candidate may be an unlicensed physician who graduated from a medical school listed in the World Directory of Medical Schools AND meets eligibility requirements to apply for the ECFMG Certification.

Licenses and Certifications:

• Registered Nurse (RN) [Required] OR Physician Assistant (PA) [Required] OR Certified Registered Nurse Practitioner (CRNP) [Required] OR Advanced Practice Registered Nurse (APRN) [Required]ORMedical Doctor (MD) [Required] OR Doctor of Osteopathic Medicine (DO) [Required] OR Educational Commission for Foreign Medical Graduates (ECFMG) [Required]
• Certified Clinical Documentation Specialist (CCDS) [Required]

Physical Requirements:

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

Pay Range:

$72,786.83 - $135,385.27

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/

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