Clinical Documentation Second Level Reviewer I

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.

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

• Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance

• Paid Time Off from Day One

• 403-B Retirement Plan

• 4 Weeks 100% Paid Parental Leave

• Career Development

• Whole Person Well-being Resources

• Mental Health Resources and Support

• Pet Benefits

Schedule:

Full time

Shift:

Day (United States of America)

Address:

601 E Rollins St

City:

Orlando

State:

Florida

Postal Code:

32803

Job Description:

Shift Information: Monday to Friday, 40 hrs – Flexible hours may be between 6:00 a.m. – 6:30 p.m

Location – Fully Virtual
 

Responsible for strategically facilitating and obtaining appropriate and quality physician documentation for clinical conditions or procedures to support the severity of illness, expected risk of mortality, and complexity of care. This position educates members of the patient care team regarding documentation guidelines. This role adheres to strict departmental and organizational goals, objectives, standards of performance, and policies and procedures. In addition, this position ensures quality documentation and regulatory compliance. Additionally, this role collaborates with physicians, nursing, and health information management coders.

• Recognizes opportunities for documentation improvement using strong critical-thinking skills and formulates clinically credible clarifications for inpatients.
• Transcribes documentation clarifications as appropriate to ensure documentation compliance.
• Educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, and nursing staff.
• Communicates effectively with physicians and other healthcare providers to ensure appropriate, accurate, and complete clinical documentation.
• Collaborates with health information management staff to resolve discrepancies with diagnostic assignments and other coding issues.

Knowledge, Skills, and Abilities:

• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations.

• Excellent computer and keyboarding skills; ability to use multiple software programs simultaneously; high degree of prioritization skills.

• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist.

• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills.

• Knowledge of pathophysiology, disease processes and treatments.

• Strong ability to organize/triage work and manage multiple priorities at once. [Required]

• Knowledge of clinical documentation requirements that identify clinical conditions or procedures.

• Coding background.

Education:

• Bachelor's of Nursing [Required]

• Master's [Preferred]

Field of Study:

• in healthcare related field

Work Experience:

• 5+ years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience. [Required] 

• 3+ years of Clinical Documentation Specialist experience [Required] 

Additional Information:

• An equivalent combination of education and relevant work experience may be considered in lieu of the stated degree requirement:- BSN and 3+ years of Clinical Documentation Specialist experience OR – 4+ years of Clinical Documentation Specialist experience OR -Less than 2 years of Clinical Documentation Integrity experience and 10 years of acute care nursing experience.

Licenses and Certifications:

• Registered Nurse (RN) [Required] OR

• Adult Acute Care Nurse Practitioner (ACNPC) [Required] OR

• Physician Assistant (PA) [Required] OR

• Certified Clinical Documentation Specialist (CCDS) [Required] OR

• Certified Documentation Improvement Practitioner (CDIP) [Required]

• Certified Coding Specialist (CCS) [Preferred]

Physical Requirements: (Please click the link below to view work requirements)

Physical Requirements –https://tinyurl.com/23km2677

Pay Range:

$66,170.74 – $123,073.07

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