About the position
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. 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, 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.
Responsibilities
- Demonstrates extending the healing ministry of Christ, through behavioral whole care standards of love me, make it easy, own it and keep me safe to every person they meet.
- Delivers exceptional care and strives for excellence.
- Committed to improving the health, prosperity and well-being of the communities we serve.
- Uphold the highest standards, with integrity driving every decision made and every action taken.
- Guided by relentless stewardship in the management of resources entrusted to them.
- Reviews concurrent medical record for documentation 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 and continues to educate self and team members.
- 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.
- Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs and HACs to ensure documentation compliance.
- Strategically educates members of the patient-care team regarding documentation regulations and guidelines.
- Effectively and appropriately communicates with physicians and other healthcare providers as necessary.
- Completes well-timed follow-up case reviews on all cases with priority given for resolution of those with clinical documentation clarifications.
- Participates in department meetings, including feedback on outstanding issues and presentations for educational opportunities.
- Assumes personal responsibility for professional growth, development and continuing education.
- Proficient in formulating valid clarifications that are easily understood by physicians and other members of the medical team.
- Accurately reconciles all cases in CDI Software.
- Assists in new hire orientation through precepting and mentoring.
- Maintains CCDS credentialing.
Requirements
- Associate degree and 5 years experience.
- 5 years acute care experience.
- 2 years CDI experience.
- 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.
- CCDS (Certified Clinical Documentation Specialist) certification, or/and CDIP (Certified Documentation Improvement Practitioner) certification.
Nice-to-haves
- BSN or higher degree and 3 years of CDI experience.
- CCS (Certified Coding Specialist).
Benefits
- Benefits from Day One
- Career Development
- Whole Person Wellbeing Resources
- Mental Health Resources and Support
