Remote Clinical Documentation Specialist I

adventhealth; Celebration (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

PTO from day one

403(b) plan

Parental leave 4 weeks

Career development

Well-being resources

Mental health resources

Pet benefits

Job summary

AdventHealth is seeking a Clinical Documentation Specialist to support adult services in a fully virtual role. You will educate care teams on documentation guidelines, communicate with physicians for precise records, and drive timely chart reviews and coding accuracy from a remote setting in the United States.

The role requires RN credentials, 5+ years in acute care, and a strong understanding of SOI-ROM quality metrics.

Qualifications

• RN license required with applicable state credentials.
• 5+ acute care nursing experience in medical/surgical, ICU, or ED.
• Knowledge of clinical documentation requirements and guidelines.

Responsibilities

• Educate patient-care team on documentation regulations and guidelines.
• Communicate with physicians to ensure accurate clinical documentation.
• Collaborate to resolve discrepancies in coding and assignments.
• Conduct follow-up case reviews for concurrent cases needing clarification.
• Participate in department meetings and provide educational opportunities.
• Maintain 95% physician response rate to clarifications.
• Review records for SOI, ROM, and quality compliance.
• Input data into CDI software and generate accurate metrics.
• Create CDI severity worksheets and suggest documentation improvements.
• Transcribe clarifications to ensure documentation compliance.

Skills

Interpersonal skills

Verbal communication

Written communication

Documentation clarity

Critical thinking

Prioritization

Education

Bachelor's in Nursing

Master's in Nursing

Tools

CDI Software

Job description

AdventHealth is seeking a Clinical Documentation Specialist to support adult services in a fully virtual role. You will educate care teams on documentation guidelines, communicate with physicians for precise records, and drive timely chart reviews and coding accuracy from a remote setting in the United States.

The role requires RN credentials, 5+ years in acute care, and a strong understanding of SOI-ROM quality metrics.