Clinical Documentation Specialist I

AdventHealth • Orlando, FL

3d • Onsite

About The Position

The Clinical Documentation Specialist I supports accurate, complete, and compliant clinical documentation by educating patient-care team members—including physicians, allied health practitioners, and nursing staff—on documentation regulations and guidelines. The role reviews concurrent inpatient medical records for completeness, accuracy, severity of illness, risk of mortality, and quality; identifies opportunities to improve documentation; and develops clinically credible clarifications and CDI severity worksheets. The specialist communicates with healthcare providers, follows up on concurrent cases, resolves documentation and coding issues with staff, and enters data into CDI software to support accurate metrics and reconciliation. The position also participates in department meetings and contributes feedback and educational opportunities. The role is full-time, day shift, and based in Orlando, Florida.

Requirements

• At least 5 years of acute-care nursing experience, specifically in medical/surgical, intensive care, post-acute care, or emergency department settings.
• An active qualifying credential is required: Registered Nurse (RN), Physician Assistant (PA), Medical Doctor (MD), Certified Registered Nurse Practitioner (CRNP), Adult Acute Care Nurse Practitioner (ACNPC), or Educational Commission for Foreign Medical Graduates (ECFMG).
• Excellent interpersonal skills, verbal and written communication skills, and physician-relations skills.
• Ability to organize and present information clearly and concisely.
• Excellent computer and keyboarding skills, including the ability to use multiple software programs simultaneously.
• Strong prioritization skills and ability to organize and triage work while managing multiple priorities.
• Ability to learn, develop, and refine the skills needed to perform effectively as a Clinical Documentation Specialist.
• Dependable, self-motivated, and pleasant.
• Strong critical-thinking, problem-solving, and deductive-reasoning skills.
• Knowledge of pathophysiology, disease processes, and treatments.

Nice To Haves

• Knowledge of clinical documentation requirements for identifying clinical conditions or procedures.
• Coding background.
• Knowledge of quality guidelines.
• Bachelor's degree in Nursing.
• Master's degree in Nursing.
• Field of study completed in health service administration, business administration, system performance engineering, industrial engineering, or public health.
• Clinical Documentation Specialist experience.
• Certified Clinical Documentation Specialist (CCDS).
• Certified Documentation Improvement Practitioner (CDIP).

Responsibilities

• Educate physicians, allied health practitioners, nursing staff, and other patient-care team members about documentation regulations and guidelines.
• Communicate with physicians and other healthcare providers to support appropriate, accurate, and complete clinical documentation.
• Collaborate with staff to resolve assignment discrepancies and coding issues.
• Conduct timely follow-up reviews of concurrent cases, prioritizing cases requiring clinical documentation clarification.
• Participate in department meetings, provide feedback on outstanding issues, and present educational opportunities.
• Maintain a 95% physician response rate to valid clarifications.
• Review concurrent medical records for compliance, completeness, and accuracy related to severity of illness, risk of mortality, and quality.
• Complete accurate and timely record reviews to ensure documentation compliance and integrity.
• Enter data accurately into CDI software to support precise metrics through the reconciliation process.
• Initiate and formulate CDI severity worksheets and clinically credible clarifications for inpatients, identifying opportunities to improve documentation compliance.
• Transcribe documentation clarifications as appropriate to ensure documentation compliance.
• Perform other duties as assigned.

Benefits

• Medical, dental, and vision insurance from day one.
• Life insurance and disability insurance from day one.
• Paid time off from day one.
• 403(b) retirement plan.
• Four weeks of 100% paid parental leave.
• Career development.
• Whole-person well-being resources.
• Mental health resources and support.
• Pet benefits.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed