Clinical Documentation Specialist II Exempt

AdventHealth; Calhoun (GA); On-site; USD 63,000 - 118,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

PTO from Day One

403(b) Retirement Plan

Parental Leave

Career Development

Well-being Resources

Mental Health Resources

Pet Benefits

Job summary

AdventHealth in Calhoun, GA seeks a Clinical Documentation Specialist II Exempt to ensure accurate documentation and regulatory compliance. You will input data into CDI software, and drive opportunities for documentation improvement across inpatient teams.

Collaborating with physicians, HIM, and nursing staff, you will educate on guidelines, review records for accuracy, and resolve DRG and coding issues while maintaining a high physician response rate and contributing to quality outcomes.

Qualifications

• Associates degree required.
• Registered Nurse license or equivalent required.
• 4+ years acute care nursing experience.
• 2+ years clinical documentation experience.

Responsibilities

• Input data into CDI software accurately.
• Identify opportunities for documentation improvement.
• Educate care team on documentation guidelines and regulations.
• Collaborate with HIM to resolve DRG discrepancies.
• Complete timely record reviews and follow-ups.

Education

Associates

RN licensure or equivalent

Field of Study: Nursing

Interpersonal skills

Verbal communication

Written communication

Critical thinking

Attention to detail

Tools

CDI Software

Job description

Our Promise To YouJoining 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

ScheduleFull time

ShiftDay (United States of America)

Address1035 RED BUD RD NE

CityCALHOUN

StateGeorgia

Postal Code30701

Job Description

• The Clinical Documentation Specialist II Exempt inputs data into CDI Software accurately and concisely, resulting in precise metrics obtained through the reconciliation process.
• Recognizes opportunities for documentation improvement using strong critical-thinking skills.
• Uses critical thinking and sound judgment in decision-making, balancing quality considerations with regulatory compliance.
• Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients, presenting opportunities for improved documentation compliance to physicians, nurse practitioners, and other clinical team members.
• Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs, and HACs to ensure documentation compliance.
• Educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, nursing, and collaboration with the healthcare team.
• Communicates effectively and appropriately with physicians and other healthcare providers to ensure accurate and complete clinical documentation.
• Collaborates with HIM staff to resolve discrepancies with DRG assignments and other coding issues.
• Completes well-timed follow-up case reviews on all concurrent cases, prioritizing resolution of those with clinical documentation clarifications.
• Participates in department meetings, providing feedback on outstanding issues, presentations for educational opportunities, and other needs identified by CDI leaders.
• Maintains a 98% physician response rate to all valid clarifications.
• Assists in new hire orientation through precepting and mentoring.
• Completion of educational project to be presented to CDI team yearly.
• Completes accurate and timely record reviews to ensure the integrity of documentation compliance.
• Reviews concurrent medical records for compliance, completeness, and accuracy regarding severity of illness, risk of mortality, and quality.
• Performs other duties as assigned.

Knowledge, Skills, And Abilities

• The Clinical Documentation Specialist II Exempt possesses 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. [Required]
• Coding background. [Required]
• Knowledge of quality guidelines. [Required]

Education

• Associates [Required]

Field Of Study

• In Registered Nursing or health related field

Work Experience

• 4+ years of acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience [Required]
• 2+ years of clinical documentation specialist [Required]

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) [Required]

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

Pay Range63,240.14 - 117,622.36

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