Clinical Documentation Integrity Specialist Remote

Clinical Documentation Integrity Specialist Remote Altamonte Springs, FL

AdventHealth Corporate

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• Job Schedule: Full-time
• Pay Range: $41.53 - $62.29 per hour
• Job ID: 25008880
• Job Family: Health Information Management
• Shift: 1 - Day
  
  

Hospitals, medical centers and facilities need more than physicians, nurses and specialists delivering care to our patients. A truly successful health care organization needs a thoughtful, dedicated, steady and experienced team working behind the scenes to make sure communities around the country receive the health care they need.

If you’ve also been interested in working in the health care field but aren’t a health care provider, a corporate career at AdventHealth may just be the perfect fit. We’re a faith-based health care organization headquartered in Altamonte Springs, Florida. As a national leader in quality, safety and patient satisfaction, our 92,000 team members maintain a long tradition of whole-person health by caring for the physical, emotional and spiritual needs of every patient.

Start your journey with a health care career at AdventHealth Corporate.

Every day, our fellow team members show up to work, unified by one shared mission: Extending the Healing Ministry of Jesus Christ. As a faith-based health care organization, our story is one of hope as we strive to heal and restore the body, mind and spirit. Though our facilities are spread across the country, this unwavering belief binds us together. Across every office, exam and patient room, we’re committed to providing individualized, holistic care. This is our Christian mission, and it inspires us to help make communities healthier and happier.

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
  
  

Shift : Full-time; Monday-Friday

Job Location : Remote

The Role You Will 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 obtainsappropriate 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 You Will Bring To The Team

• 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.
• 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, presentations for educational opportunities and any other needs identified by the CDI leaders.
• Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.
• 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
  
  

The Expertise And Experiences You’ll Need To Succeed

• Associate and 5 years experience
• 5 years acute care
• 2 years CDI experience
  
  

Licensure, Certification Or Registration Required

• 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 and
• CCDS (Certified Clinical Documentation Specialist) certification, or/and CDIP (Certified
• Documentation Improvement Practitioner) certification
  
  

Preferred Qualifications

• BSN or higher degree and 3 years of CDI experience
• CCS (Certified Coding Specialist)
  
  

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

Category: Health Information Management

Organization: AdventHealth Corporate

Schedule: Full-time

Shift: 1 - Day

Req ID: 25008880

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.

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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.