Clinical Document Specialist I

**All 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) + Career Development + Whole Person Wellbeing Resources **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 Fully Remote **Shift** : Days **Location** : AdventHealth East Orlando Campus– **_However,_** this position is fully remote. **The community you’ll be caring for:** AdventHealth East Orlando + AdventHealth East Orlando, a 265-bed community hospital, has been serving East Orlando residents since 1941 as an innovative local leader that fills a vital need in a fast-growing area + A recent 200,000 square-foot expansion project upgraded the hospital to 265 beds, with a spacious patient tower and 80 new private rooms designed to enhance the holistic care experience + Annual number of emergency cases: 89,018 **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 obtain 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 attending 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’ll bring to the team:** •Demonstrates, through behavior, Integrity, Compassion, Balance, Excellence, Stewardship, and Teamwork •Reviews concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies. •Completes accurate and timely record review to ensure the integrity of documentation compliance. Completes accurate and concise input of data into CDMP Trak resulting in accurate metrics provided by the CDMP program. Understands and supports CDMP documentation strategies (upon completion of training) and continues to educate self and team members using educational tools, videos and provided WebEx's. •Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping reimbursement considerations in balance with regulatory compliance. Initiates/formulates CDMP severity worksheets and clinically credible clarifications for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other medical staff. •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 attending physicians, allied health practitioners, nursing, and care management. This includes quarterly compliance updates from Medicare. Qualifications **The expertise and experiences you’ll need to succeed** **:** Associate and 0 years experience Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience. LICENSURE, CERTIFICATION OR REGISTRATION: Please be advised that all licenses and certifications listed are not required. If you only have one or some of those listed, you may still be eligible for this position. 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. 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:** Clinical/Medical Informatics **Organization:** AdventHealth East Orlando **Schedule:** Full-time **Shift:** 1 - Day **Req ID:** 24041242 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.