Clinical Documentation Integrity Specialist II

Dormont Manufacturing Co; United States; On-site; USD 66,999 - 124,618; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

Paid Time Off

403-B Retirement Plan

Parental Leave 4 weeks

Career Development

Well-being Resources

Mental Health Resources

Pet Benefits

Job summary

AdventHealth is seeking a Clinical Documentation Specialist to ensure accurate, compliant medical documentation across inpatient and outpatient settings. The role emphasizes strong communication with physicians and the healthcare team, and a commitment to documenting severity of illness, risk of mortality, and quality.

You will work with CDI leadership, perform chart reviews, educate care teams, and support DRG assignments while maintaining a high physician response rate.

Qualifications

• Associates degree required; field of study in nursing or health-related area.
• Proven knowledge of clinical documentation requirements and coding.
• Experience with CDI and documentation improvement processes.

Responsibilities

• Educates care team on documentation regulations and guidelines.
• Communicates with physicians and healthcare providers to ensure accurate documentation.
• Reviews records for accuracy regarding severity of illness, risk of mortality, and quality.
• Maintains high physician response rate to clarifications.
• Performs timely chart reviews and follows up on concurrent cases.

Skills

Interpersonal skills

Communication skills

Computer skills

Prioritization

Critical thinking

Pathophysiology knowledge

Organization

Clinical documentation knowledge

Coding background

Quality guidelines

Education

Associates

Field of study: nursing/health

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:

9100 W 74TH ST

City:

SHAWNEE MISSION

State:

Kansas

Postal Code:

66204

Job Description:

• JATA Trained Preferred
• Inputs data into CDI Software accurately and concisely, resulting in precise metrics obtained through the reconciliation process.
• Recognizes opportunities for documentation improvement using strong critical‑thinking skills.
• Uses critical thinking and sound judgment in decision‑making, balancing quality considerations with regulatory compliance.
• Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients, presenting opportunities for improved documentation compliance to physicians, nurse practitioners, and other clinical team members.
• Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs, and HACs to ensure documentation compliance.
• Educates members of the patient‑care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, nursing, and collaboration with the healthcare team.
• Communicates effectively and appropriately with physicians and other healthcare providers to ensure accurate and complete clinical documentation.
• Collaborates with HIM staff to resolve discrepancies with DRG assignments and other coding issues.
• Completes well‑timed follow‑up case reviews on all concurrent cases, prioritizing resolution of those with clinical documentation clarifications.
• Participates in department meetings, providing feedback on outstanding issues, presentations for educational opportunities, and other needs identified by CDI leaders.
• Maintains a 98% physician response rate to all valid clarifications.
• Assists in new hire orientation through precepting and mentoring.
• Completion of educational project to be presented to CDI team yearly.
• Completes accurate and timely record reviews to ensure the integrity of documentation compliance.
• Reviews concurrent medical records for compliance, completeness, and accuracy regarding severity of illness, risk of mortality, and quality.
• 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. [Required]
• Coding background. [Required]
• Knowledge of quality guidelines. [Required]

Education:

• Associates

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+ years of clinical documentation specialist [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] 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) [Required]

Physical Requirements:

Please click the link below to view work requirements

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

Pay Range:

$66,999.24 - $124,618.59

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