Clinical Doc Specialist II Non-Lic

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.

• Reviews concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM) and quality.
• Completes accurate and timely record review to ensure the integrity of documentation compliance.
• Completes accurate and concise input of data into CDI Software resulting in accurate metrics obtained through the reconciliation process.
• Understands and supports CDI documentation strategies (upon completion of didactic training) and continues to educate self and team members, by attending monthly mandated education sessions and using educational tools, videos and provided Webinars.
• Recognizes opportunities for documentation improvement using strong critical-thinking skills.
• Uses critical thinking and sound judgment in decision making keeping quality considerations in balance with regulatory compliance.
• Initiates/formulates CDI severity worksheets and clinically credible clarifications for inpatients, sending/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 is accomplished.
• Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, nursing, and collaboration with the healthcare team.
• This includes quarterly and annual compliance updates from Medicare.
• Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation.
• Communicate with HIM staff and collaborate with them to resolve discrepancies with DRG assignments and other coding issues.
• Complete well-timed follow-up case reviews on all concurrent cases with priority given for resolution of those with clinical documentation clarifications.
• Participate in department meetings, including feedback on outstanding issues, presentations on educational opportunities and any other needs identified by the CDI leaders.
• Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.
• Demonstrates competence in chart audits.
• Correctly identifies physician clarification opportunities.
• Proficient in formulating valid clarifications that are easily understood by physicians and other members of the medical team.
• Accurately reconciles all cases in CDI database.
• Maintains a 95% physician response rate to all valid clarifications.
• Performs other duties as assigned.

• 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]

• High School Grad or Equiv [Required]

• 4+ acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience [Required]
• 5+ Coding Experience [Required]

• Certified Clinical Documentation Specialist (CCDS) [Preferred]

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.