Second Level Reviewer I

adventhealth; Orlando (FL); On-site; USD 66,170 - 123,073; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Paid Time Off

403(b) Plan

Parental Leave (4 weeks)

Career Development

Well-being Resources

Mental Health Resources

Pet Benefits

Job summary

AdventHealth in Altamonte Springs, Florida is seeking a Clinical Documentation Specialist to drive documentation accuracy and coding quality. The role collaborates with physicians, nursing staff and health information management to clarify diagnoses and ensure compliant records.

Ideal candidates hold a BSN with 5+ years of acute care nursing and 3+ years in clinical documentation. A CCDS/CDIP or CCS preferred; strong communication and prioritization are essential.

Qualifications

• 5+ years acute care nursing experience in medical/surgical, ICU, post-acute, or ED.
• 3+ years Clinical Documentation Specialist experience.
• Equivalent combination of education and relevant work experience may be considered.

Responsibilities

• Recognizes opportunities for documentation improvement and clarifications for inpatients.
• Transcribes documentation clarifications to ensure compliance.
• Educates care team on documentation regulations and guidelines.

Skills

Interpersonal skills

Communication

Organization

Computer skills

Critical thinking

Pathophysiology knowledge

Prioritization

Clinical documentation knowledge

Education

Bachelor's of Nursing

Master's

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:

900 HOPE WAY

City:

ALTAMONTE SPRINGS

State:

Florida

Postal Code:

32714

Job Description:

• Recognizes opportunities for documentation improvement using strong critical-thinking skills and formulates clinically credible clarifications for inpatients.
• Transcribes documentation clarifications as appropriate to ensure documentation compliance.
• 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 health information management staff to resolve discrepancies with diagnostic assignments and other coding issues.
• Completes well-timed follow-up case reviews on all cases, prioritizing those with clinical documentation clarifications.
• Participates in department meetings, providing feedback on outstanding issues and presenting educational opportunities.
• Assumes personal responsibility for professional growth, development, and continuing education to maintain a high level of proficiency.
• Assists in new hire orientation through precepting and mentoring.
• Maintains regional productivity standards and demonstrates competence on compliance audit scores.
• Maintains a 97% physician response rate to all valid clarifications.
• Annual participation in Advanced Practice call. Maintains CCDS credentialing.
• Other duties as assigned.
• Reviews concurrent medical records for documentation compliance, including completeness, accuracy and quality.
• Inputs data accurately and concisely into assigned software, resulting in accurate metrics obtained through the reconciliation process.

Knowledge, Skills, and Abilities:

• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations.
• 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.
• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist.
• Dependable, self-motivated, and pleasant.
• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills.
• Knowledge of pathophysiology, disease processes and treatments.
• Strong ability to organize/triage work and manage multiple priorities at once. [Required]
• Knowledge of clinical documentation requirements that identify clinical conditions or procedures.
• Coding background.
• Knowledge of quality guidelines. [Preferred]

Education:

• Bachelor's of Nursing [Required]
• Master's [Preferred]

Field of Study:

• in healthcare related field

Work Experience:

• 5+ years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience. [Required]
• 3+ years of Clinical Documentation Specialist experience[Required]

Additional Information:

• An equivalent combination of education and relevant work experience may be considered in lieu of the stated degree requirement:- BSN and 3+ years of Clinical Documentation Specialist experience OR - 4+years of Clinical Documentation Specialist experience OR -Less than 2 years of Clinical Documentation Integrity experience and 10 years of acute care nursingexperience.

Licenses and Certifications:

• Registered Nurse (RN) [Required] OR
• Adult Acute Care Nurse Practitioner (ACNPC) [Required] OR
• Physician Assistant (PA) [Required] OR
• Certified Clinical Documentation Specialist (CCDS) [Required] OR
• Certified Documentation Improvement Practitioner (CDIP) [Required]
• Certified Coding Specialist (CCS) [Preferred]

Physical Requirements:

(Please click the link below to view work requirements)

Physical Requirements - https://tinyurl.com/23km2677

Pay Range:

$66,170.74 - $123,073.07

Background Screening Requirement (Florida Law)

Certain positions are subject 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.