Clinical Documentation Integrity Specialist Remote Job at AdventHealth, Altamonte Springs, FL

V24zVXpHLzZQeGZUTXlnTXhKMjJFUnlyNFE9PQ==
  • AdventHealth
  • Altamonte Springs, FL

Job Description

**AdventHealth Corporate**

**All the benefits and perks you need for you and your family:**

Benefits from Day One

Career Development

Whole Person Wellbeing Resources

Mental Health Resources and Support

**Our promise to you:**

Joining AdventHealth is about being part of something bigger. Its 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.

**Shift** : Monday-Friday; Full-time

**Job Location** : Remote

**The role youll contribute:**

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.

**The value that you bring to the team:**

1 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 (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.

Qualifications

**The expertise and experiences youll need to succeed** **:**

Associate and 5 years experience

5 years acute care

Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.

3 years of Clinical Documentation Specialist 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 (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/and CDIP (Certified Documentation Improvement Practitioner) certification

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

**Category:** Health Information Management

**Organization:** AdventHealth Corporate

**Schedule:** Full-time

**Shift:** 1 - Day

**Req ID:** 24029401

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.

AdventHealth

Job Tags

Remote job, Full time, Local area, Shift work, Monday to Friday,

Similar Jobs

Sanford Health

RN - Registered Nurse - Chamberlain Medical Center - Full Time Job at Sanford Health

 ...joining our team of over 18,000 nurses. Our workplace culture focuses...  ...Job Schedule: Full time Weekly Hours: 40.00...  ...positive, compassionate, hardworking registered nurses (RN) who can provide the...  ...for qualifying full-time and part-time employees. Depending on eligibility... 

Prisma Health Urgent Care by Wellstreet

Urgent Care Nurse Practitioner/Physician Assistant Job at Prisma Health Urgent Care by Wellstreet

Prisma Health Urgent Care seeks talented, patient-oriented Physician Assistants and Nurse Practitioners who are relentlessly dedicated to ensure the delivery of exceptional customer service by putting patients needs first. Prisma HealthUrgent Care has emerged as a leading... 

Client Server Software Solutions

COMPUTER NETWORK SYSTEMS ADMINISTRATOR Job at Client Server Software Solutions

 ...preferred subcontractor, we have a continual list of opportunities to fill nationwide with multiple agencies such as the Department of Veteran Affairs, the Department of Defense, civilian agencies, and the national intelligence community. Many positions supporting the U.S.... 

Supplemental Health Care

Travel Physicist - $6,721 per week Job at Supplemental Health Care

 ...years of recent Physicist experience Supplemental Health Care will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable local, state, or federal law (including San Francisco Ordinance #131192... 

Milestone Tomahawk

Assisted Living Caregiver/Medication Aide (CBRF) Job at Milestone Tomahawk

 ...PTO) program ~401k with 5% Match ~ Great benefits including medical, dental, vision, life and more (FT Only) What You Will Do:...  ...(PCA), Certified Nursing Assistant (CNA), Certified Medication Aide (CMA), Universal Worker The Minnesota Equal Pay for Equal Work...