Address
Form of workAll the benefits and perks you need for you and your family:
- Benefits from Day One
- Paid Days Off from Day One
- Debt-free Education* (Certifications and Degrees without out-of-pocket tuition expense)
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.
Schedule: Full Time
Shift: Day
The community you'll be caring for:
- The Maitland Office Plaza houses our highly skilled teams that support our hospital system including Marketing, Patient Financial Services, Revenue Management, the Credit Union and Human Resources.
- The Trickle Building, a two-story office structure, creates an atmosphere of health and healing, with a healthy-style cafe and quaint chapel.
- The main lobby is filled with lush greenery and a light trickle of water, creating a holistic environment.
The role you'll contribute:
Under general supervision of the Director of Clinical Documentation Integrity, and in collaboration with physicians, nursing and HIM coders, the Documentation Quality Reviewer (DQR), is responsible for reviewing medical records for quality and core measures. The DQR 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, and to support ICD-10 codes. The DQR collects data, analyzes data and reports data to CDI Director. The DQR educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and care management. The DQR will act as a liaison to the CDI and coding staff. The DQR will serve as a resource to the CDI team, CDI Educator, CDI Managers and CDI Director. The DQR adheres to departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance.
The value you'll bring to the team:
- Demonstrates, through behavior, Florida Hospital's core values of Integrity, Compassion, Balance, Excellence, Stewardship, and Teamwork.
- Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies.
- Conducts audits for quality including, but not limited to deceased second level reviews, focused disease process reviews as needed, patient safety indicators, CDI team audits. Collects data, analyzes data and reports data to CDI Director and CDI Leadership team.
- Completes accurate and timely record review. Recognizes opportunities for documentation improvement.
- Educates members of the patient-care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and care management.
- Initiates CDMP severity worksheet for inpatients.
- Effectively and appropriately communicates with physicians.
- Completes timely follow-up on all cases and resolution of those with Clinical Documentation clarifications. Formulates clinically credible documentation clarifications. Requests documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety.
- Manages multiple priorities. Participates in Task Forces and Quality Management Meetings.
- Collaborates with coding and quality team to communicate discrepancies in the capture of patient safety indicators, Hospital acquired infections, Hospital acquired conditions, and core measures. Communicates with HIM staff and resolves discrepancies. Completes accurate input of documentation into CDMP Trak.
EXPERIENCE REQUIRED:
- Two (2) years of Clinical Documentation Specialist experience
- Five (5) years of adult acute care experience in med/surg, critical care, emergency room, or PACU
EDUCATION AND EXPERIENCE PREFERRED:
- Five (5) years of adult acute care experience in med/surg, critical care, emergency room, or PACU
- BSN or MSN
LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:
- Current valid State of Florida or multi state license as a Registered Nurse
LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:
- CCDS, CDIP, CCS
