Clinical Documentation Integrity Specialist Remote

AdventHealth; Altamonte Springs (FL); Remote; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a Clinical Documentation Specialist to enhance patient care through accurate documentation. In this role, you will collaborate with healthcare professionals to ensure compliance and quality in clinical records. This position offers the opportunity to thrive in a supportive environment that values your contributions to community health. You will play a vital role in educating teams on documentation standards and improving clinical outcomes. If you are passionate about making a difference in healthcare and possess strong analytical skills, this could be your next career move.

Benefits

Benefits from Day One

Career Development

Whole Person Wellbeing Resources

Mental Health Resources and Support

Qualifications

• 5 years of experience in acute care and 2 years in CDI.
• Current active State license as a Registered Nurse or equivalent.

Responsibilities

• Facilitates quality physician documentation for clinical conditions.
• Educates patient care team on documentation guidelines.

Skills

Critical Thinking

Documentation Compliance

Communication Skills

Customer Service

Education

Associate Degree

BSN or higher degree

Tools

CDI Software

Job description

AdventHealth Corporate

All the benefits and perks you need for you and your family:

1. Benefits from Day One
2. Career Development
3. Whole Person Wellbeing Resources
4. Mental Health Resources and Support

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.

Shift: Full-time; Monday-Friday

Job Location: Remote

The role you will 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 will bring to the team:

1. 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.
2. Reviews concurrent medical records for documentation compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), and quality.
3. 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.
4. 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.
5. Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs, and HACs to ensure documentation compliance is accomplished.
6. Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, nursing, and collaboration with the healthcare team. This includes quarterly and annual compliance updates from Medicare.
7. Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate, and complete clinical documentation. Communicates with HIM staff and collaborates with them to resolve discrepancies with DRG assignments and other coding issues.
8. Completes well-timed follow-up case reviews on all cases with priority given for resolution of those with clinical documentation clarifications.
9. Participates in department meetings, including feedback on outstanding issues, presentations for educational opportunities, and any other needs identified by the CDI leaders.
10. Assumes personal responsibility for professional growth, development, and continuing education to maintain a high level of proficiency.
11. Proficient in formulating valid clarifications that are easily understood by physicians and other members of the medical team.
12. Accurately reconciles all cases in CDI Software.
13. Assists in new hire orientation through precepting and mentoring.
14. Maintains CCDS credentialing.

The expertise and experiences you’ll need to succeed:

1. Associate and 5 years experience
2. 5 years acute care
3. 2 years CDI experience

Licensure, Certification or Registration Required:

1. 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.
2. CCDS (Certified Clinical Documentation Specialist) certification, or/and CDIP (Certified Documentation Improvement Practitioner) certification.

Preferred Qualifications:

1. BSN or higher degree and 3 years of CDI experience
2. CCS (Certified Coding Specialist)

This facility is an equal opportunity employer and complies with federal, state, and local anti-discrimination laws, regulations, and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience, and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

Category: Health Information Management

Organization: AdventHealth Corporate

Schedule: Full-time

Shift: 1 - Day

Req ID: 25008880

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age, or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits, and other terms and conditions of employment.