Clinical Documentation Specialist I

adventhealth; Daytona Beach (FL); On-site; USD 66,000 - 123,000; Full time

Benefits offered by this job

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 summary

AdventHealth in Daytona Beach is seeking a Clinical Documentation Specialist to educate care teams on documentation standards, work with physicians to ensure accurate coding, and resolve discrepancies across records. This full-time role emphasizes timely reviews and high quality metrics.

The position requires 4+ acute care nursing experience, a nursing-related associates degree, and relevant licenses. Florida-based work with comprehensive benefits from day one is offered.

Qualifications

• Associates degree required.
• Field of study in nursing or health-related field.
• 4+ acute care nursing experience required.
• Licensure: RN/PA/CRNP/APRN/MD/DO/ECFMG depending on role.

Responsibilities

• Educates patient-care team on documentation regulations and guidelines.
• Communicates with physicians and providers to ensure accurate clinical documentation.
• Resolves discrepancies with assignments and coding issues.
• Performs timely follow-up case reviews on concurrent cases.
• Participates in department meetings and presents educational opportunities.
• Maintains a 95% physician response rate to valid clarifications.
• Reviews records for SOI and ROM and quality compliance.
• Inputs data into CDI software for accurate metrics.
• Prepares severity worksheets and clarifications for inpatients.
• Transcribes clarifications to ensure documentation compliance.
• Other duties as assigned.

Skills

Interpersonal skills

Verbal and written communication

Organize information

Prioritization

Critical thinking

Pathophysiology knowledge

Documentation knowledge

Quality guidelines knowledge

Problem solving

Education

Associates

Field of study: nursing/health related

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

301 MEMORIAL MEDICAL PKWY

City

DAYTONA BEACH

State

Florida

Postal Code

32117

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]
• 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]
• 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]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) [Preferred]

Physical Requirements

(Please click the link below to view work requirements)

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

Pay Range

$66,170.74 - $123,073.07

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.