Clinical Documentation Integrity Specialist

1103 Team Member Services; United States; On-site; USD 67,000 - 124,000; Full time

Benefits offered by this job

Medical, Dental, Vision Insurance

Life Insurance

Disability Insurance

Paid Time Off from Day One

403-B Retirement Plan

4 Weeks Parental Leave

Career Development

Whole Person Well-being Resources

Mental Health Resources

Pet Benefits

Job summary

AdventHealth in Tampa, FL seeks a Clinical Documentation Specialist (RN/PA) to educate care teams on documentation rules and improve chart accuracy. You will collaborate with physicians, resolve coding discrepancies, and generate CDI severity worksheets to support compliant documentation.

The role requires nursing licensure, an associates degree in a health field, and experience in clinical documentation; CCDS is preferred. Day shift opportunities with comprehensive benefits.

Qualifications

• RN license/registration required.
• Associates degree in nursing or health-related field.
• Clinical Documentation Specialist experience preferred.
• CCDS certification preferred.

Responsibilities

• Educates patient-care team on documentation regulations and guidelines.
• Communicates with physicians and providers to ensure accurate charts.
• Collaborates to resolve coding discrepancies.
• Inputs data into CDI software and creates severity worksheets.
• Participates in department meetings and provides education.
• Maintains a high physician response rate to clarifications.

Skills

Interpersonal skills

Verbal and written communication

Physician relations

Organization & presentation

Critical-thinking

Pathophysiology knowledge

Prioritization

Education

Associate degree in 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 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: 3100 E FLETCHER AVE City: TAMPA State: Florida Postal Code: 33613

Job Description:

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 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. Maintains a 95% physician response rate to all valid clarifications. Reviews concurrent medical records for 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 accurately into CDI Software, resulting in precise metrics obtained through the reconciliation process. 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.

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] Utilise 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] Clinical Documentation Specialist experience [Preferred]

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] OR Medical Doctor (MD) [Required] OR Doctor of Osteopathic Medicine (DO) [Required] OR Educational Commission for Foreign Medical Graduates (ECFMG) [Required] Certified Clinical Documentation Specialist (CCDS) [Preferred]

Physical Requirements:

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

Pay Range:

$66,830.40 - $124,300.80

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.

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.