Clinical Documentation Specialist I

1103 Team Member Services; Minneola (CA); Remote; USD 67,000 - 124,000; Full time

Benefits offered by this job

Medical, dental, vision insurance

403-B Retirement Plan

Paid Parental Leave

Career development

Job summary

AdventHealth in Minneola, FL seeks a Clinical Documentation Specialist to enhance documentation quality across physician queries and chart reviews.

The role requires RN licensure and a strong nursing background, preferably in obstetrics or NICU settings, with emphasis on accurate coding guidance and interdisciplinary collaboration.

Qualifications

• This role requires RN licensure and clinical documentation expertise.
• Experience in obstetrics, high-risk obstetrics, or newborn care is preferred.
• Strong communication and documentation skills are essential.

Responsibilities

• Educates patient care team on documentation guidelines and regulations.
• Collaborates with physicians and nurses to ensure accurate clinical documentation.
• Reviews records for completeness and accuracy related to SOI, ROM, and quality.
• Inputs data into CDI software and prepares severity worksheets.
• Performs follow-up reviews and participates in department meetings.

Skills

RN license

Clinical documentation

Communication skills

multitasking / prioritization

Education

Bachelor's of Nursing

Master's of Nursing

Field of Study: health service administration or public 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 and Location

Schedule: Full time Shift: Day (United States of America) Address: 1800 N HANCOCK RD City: MINNEOLA State: Florida Postal Code: 34715

Job Description

Shift Information: Monday to Friday, 40 hrs – Flexible hours may be between 6:00 a.m. – 6:30 p.m Location - Fully Virtual

Strong clinical nursing background in obstetrics, high-risk obstetrics, and newborn care. NICU experience preferred but not required. Responsible for strategically facilitating and obtaining appropriate and quality physician documentation for clinical conditions or procedures. This position educates members of the patient care team regarding documentation guidelines, collaborates with multiple staff members, and adheres to departmental organizational goals. 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.

Education

• Bachelor's of Nursing [Preferred]
• Master's of Nursing [Preferred]
• Field of Study: completed in health service administration, business administration, system performance engineering, industrial engineering, or public health

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]

Licenses and Certifications

• Registered Nurse (RN) [Required]
• OR Physician Assistant (PA) [Required]
• OR Medical Doctor (MD) [Required]
• OR Certified Registered Nurse Practitioner (CRNP) [Required]
• OR Adult Acute Care Nurse Practitioner (ACNPC) [Required]
• OR Educational Commission for Foreign Medical Graduates (ECFMG) [Required]
• Certified Clinical Documentation Specialist (CCDS) [Preferred]
• Certified Documentation Improvement Practitioner (CDIP) [Preferred]

Physical Requirements

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

Pay Range

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/

Equal Opportunity Employer

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

Corporate Mission

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.