Clinical Document Specialist II

AdventHealth • Orlando, FL

41d • Remote

About The Position

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 obtains 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 physicians, allied health practitioners, nursing, 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.

Requirements

• 5 years acute care experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
• 2 years of clinical documentation specialist experience
• Current active State license as a Registered Nurse or Nurse Practitioner or Physicians 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.
• CCDS (Certified Clinical Documentation Specialist) certification OR
• CDIP (Certified Documentation Improvement Practitioner) certification

Responsibilities

• 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. Communicates with HIM staff and collaborates with them to resolves discrepancies with DRG assignments and other coding issues.
• Completes well-timed follow-up case reviews on all concurrent cases with priority given for resolution of those with clinical documentation clarifications.
• Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.
• Demonstrates competence by achieving an annual average of 90% on compliance audit scores .
• Maintains a 97% physician response rate to all valid clarifications.

Benefits

• Benefits from Day One
• Paid Time Off from Day One
• Whole Person Wellbeing Resources

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees