Clinical Document Specialist I
Company: AdventHealth
Location: Orlando
Posted on: May 25, 2023
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Job Description:
**Description**
**All the benefits and perks you need for you and your
family:**
+ Benefits from Day One
+ Paid Days Off from Day One
+ Debt-free Education* (Certifications and Degrees without
out-of-pocket tuition expense)
**Our promise to you:**
Joining AdventHealth is about being part of something bigger. Its
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.
**Schedule:** Full Time, Remote (must reside within 50 miles of
Central Florida)
**Shift** : Days
**The community youll be caring for:**
+ The Maitland Office Plaza houses our highly skilled teams that
support our hospital system including Marketing, Patient Financial
Services, Revenue Management, the Credit Union and Human
Resources.
+ The Trickle Building, a two-story office structure, creates an
atmosphere of health and healing, with a healthy-style caf and
quaint chapel.
+ The main lobby is filled with lush greenery and a light trickle
of water, creating a holistic environment.
**The role youll contribute:**
Under general supervision of the Director of Clinical Documentation
Integrity and in some situations the supervision of the Clinical
Documentation Integrity Manager, and in collaboration with
physicians, nursing and HIM coders, the Clinical Documentation
Specialist (CDS) strategically facilitates and obtain appropriate
and quality physician documentation for any clinical conditions or
procedures to support the appropriate severity of illness, expected
risk of mortality, and complexity of care of the patient. The CDS
educates members of the patient care team regarding documentation
guidelines, including attending physicians, allied health
practitioners, nursing, and care management. The CDS adheres to
strict departmental and organizational goals, objectives, standards
of performance and policies and procedures, continually ensuring
quality documentation and regulatory compliance. Actively
participates in outstanding customer service and accepts
responsibility in maintaining relationships that are equally
respectful to all
**The value youll bring to the team:**
+ Demonstrates, through behavior, Integrity, Compassion, Balance,
Excellence, Stewardship, and Teamwork
+ Reviews concurrent medical record for compliance including
completeness and accuracy for severity of illness (SOI) and quality
using the Compliant Documentation Management Program (CDMP)
documentation strategies.
+ Completes accurate and timely record review to ensure the
integrity of documentation compliance. Completes accurate and
concise input of data into CDMP Trak resulting in accurate metrics
provided by the CDMP program. Understands and supports CDMP
documentation strategies (upon completion of training) and
continues to educate self and team members using educational tools,
videos and provided WebEx's.
+ Recognizes opportunities for documentation improvement using
strong critical-thinking skills. Uses critical thinking and sound
judgment in decision making keeping reimbursement considerations in
balance with regulatory compliance. Initiates/formulates CDMP
severity worksheets and clinically credible clarifications for
inpatients, sending/presenting opportunities for improved
documentation compliance to physicians, nurse practitioners and
other medical staff.
+ Transcribes documentation clarifications as appropriate for SOI,
ROM, PSI, HCCs and HACs to ensure documentation compliance is
accomplished.
+ Strategically educates members of the patient-care team regarding
documentation regulations and guidelines, including attending
physicians, allied health practitioners, nursing, and care
management. This includes quarterly compliance updates from
Medicare.
+ Effectively and appropriately communicates with physicians and
other healthcare providers as necessary to ensure appropriate,
accurate and complete clinical documentation. Communicates with HIM
staff and collaborates with them to resolves discrepancies with DRG
assignments and other coding issues.
**Qualifications**
**The expertise and experiences you'll need to succeed:**
**EDUCATION AND EXPERIENCE REQUIRED:**
+ Minimum of five years acute care nursing experience with specific
medical/surgical, Intensive Care, post-acute care unit, or
Emergency Department experience.
**EDUCATION AND EXPERIENCE PREFERRED:**
+ BSN, MSN
+ Clinical Documentation Specialist experience
**LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:**
+ Current active State license as a Registered Nurse, Nurse
Practitioner, Physician's Assistant or an unlicensed physician who
has graduated from a medical school that is listed in the World
Directory of Medical Schools (World Directory) as meeting
eligibility requirements for its graduates to apply to the
Educational Commission for Foreign Medical Graduates (ECFMG) for
ECFMG Certification and examination at the time of graduation.
This facility is an equal opportunity employer and complies with
federal, state and local anti-discrimination laws, regulations and
ordinances.
**Category:** Clinical/Medical Informatics
**Organization:** AdventHealth Orlando
**Schedule:** 1 - Day
**Shift:** AdventHealth Orl Support
**Req ID:** 23015491We are an equal opportunity employer and do not
tolerate discrimination based on race, color, creed, religion,
national origin, sex, marital status, age or disability/handicap
with respect to recruitment, selection, placement, promotion,
wages, benefits and other terms and conditions of
employment.
Keywords: AdventHealth, Orlando , Clinical Document Specialist I, Healthcare , Orlando, Florida
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