Clinical Documentation Specialist I

adventhealth; Palm Coast (FL); On-site; USD 67,000 - 124,000; 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

Career Development

Well-being Resources

Mental Health Resources

Pet Benefits

Job summary

AdventHealth in Palm Coast, FL is seeking a Clinical Documentation Specialist to educate the patient-care team on documentation guidelines and collaborate with physicians to ensure accurate and complete clinical documentation. You will review records, resolve coding discrepancies, and contribute to quality metrics.

The ideal candidate holds an Associates degree in a health-related field and an active RN license or physician equivalent, with strong communication and critical-thinking abilities.

Qualifications

• Associates degree in nursing or health-related field required.
• RN license or equivalent required (RN/PA/CRNP/APRN/MD/DO/ECFMG).
• Strong documentation and coding knowledge preferred.
• Excellent communication and critical-thinking abilities.

Responsibilities

• Educates patient-care team on documentation regulations and guidelines.
• Communicates with physicians and providers to ensure accurate clinical documentation.
• Resolves discrepancies in assignments and coding with staff.
• Performs timely chart reviews for SOI, ROM and quality metrics.
• Participates in department meetings and provides education opportunities.
• Maintains high physician response rate to clarifications.

Skills

Interpersonal skills

Verbal communication

Written communication

Organizational skills

Prioritization

Critical thinking

Problem solving

Pathophysiology knowledge

Clinical documentation knowledge

Education

Associates degree

RN License or physician equivalent

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:

60 MEMORIAL MEDICAL PKWY

City:

PALM COAST

State:

Florida

Postal Code:

32164

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] 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) [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.