Clinical Documentation Specialist I

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

• Benefits from Day One
• Paid Days Off 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. 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
Location: AdventHealth Porter Virtual
The role you'll 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, care management and etc... 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'll 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 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. Usescritical 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.

Qualifications
The expertise and experiences you'll need to succeed:

• Achieve a 70% or greater on the AdventHealth Corporate Approved Pre-Hire Assessment.
• Achieve a 70% or greater on the Annual AdventHealth Corporate Approved Post Hire Assessment.
• Minimum of three years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department 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.