Clinical Document Specialist III

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, 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 Youll 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, continues to educate self and team members by attending monthly mandated education sessions and using educational tools, videos and provided Webinars Qualifications Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience. BSN and 3 years of Clinical Documentation Specialist experience RN - Registered Nurse - State Licensure and/or Compact State Licensure NP - Nurse Practitioner Licensed CCDS - Certified Cardiac Device Specialist in lieu of BSN CDIP - Clinical Documentation Improvement Professional in lieu of BSN Additional Information 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. Categories & Details Category: Case Management Organization: AdventHealth Orlando Schedule: Full-time Shift: Day 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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