Clinical Documentation Specialist II

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.

Responsible for facilitating and obtaining quality physician documentation for clinical conditions and procedures to support the severity of illness, risk of mortality, and complexity of patient care. This position educates the patient care team, including physicians, allied health practitioners, nursing, and care management, on documentation guidelines. In addition, this position ensures adherence to departmental and organizational goals, standards of performance, and policies and procedures. Additionally, this role continually ensures quality documentation and regulatory compliance. Responsibilities for this role include actively participating in customer service and maintaining respectful relationships with all team members. This role contributes to the overall efficiency and effectiveness of clinical documentation processes.

• 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.

• 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]

• Associates [Required]

• in nursing or health related field

• 4+ 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]

• 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.

• 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]

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.