Clinical Documentation Specialist I

AdventHealth; Orlando (FL); On-site; USD 67,000 - 124,000; Full time

Benefits offered by this job

Medical, Dental, Vision Insurance

Paid Time Off from Day One

403-B Retirement Plan

Parental Leave

Job summary

AdventHealth in Orlando, Florida is seeking a Clinical Documentation Specialist (CDI) to educate the patient-care team on documentation standards and collaborate with physicians to ensure accurate and compliant clinical records.

The role focuses on monitoring concurrent cases, resolving coding discrepancies, and generating CDI severity worksheets. Eligible candidates typically hold RN/PA/MD credentials with related CDI experience, and the position is a full-time, day-shift opportunity.

Qualifications

• 5+ acute care nursing experience with medical/surgical, ICU, post-acute, or ED experience.
• RN or equivalent licensure required; CDI Certification preferred.

Responsibilities

• Educates patient-care team on documentation regulations and guidelines.
• Communicates with physicians and healthcare providers to ensure accurate clinical documentation.
• Performs concurrent case reviews and follows up on clarifications.
• Maintains physician response rate and ensures integrity of documentation.
• Inputs data into CDI software and generates severity worksheets for inpatient cases.

Skills

Interpersonal skills

Organization & presentation

Learn/Develop CDI skills

Dependable

Critical thinking

Pathophysiology knowledge

Prioritize multiple tasks

Clinical documentation requirements

Coding background

Quality guidelines knowledge

Education

Bachelor's of Nursing

Master's of Nursing

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:

601 E Rollins St

City:

Orlando

State:

Florida

Postal Code:

32803

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:

• 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:

• 5+ 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:

• N/A

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:

(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.