Clinical Documentation Specialist Full Time- Wesley Chapel at AdventHealth

Date Posted: 11/17/2019

Job Snapshot

  • Job Schedule
    Full-Time
  • Location:
    Tampa, FL
  • Job Category
  • Date Posted:
    11/17/2019
  • Job ID:
    19014185
  • Job Family
    Quality/Clinical Effectiveness
  • Travel
    Yes, 25 % of the Time
  • Shift
    1 - Day
  • Application Zone
    1-Shared Services
  • Organization
    AdventHealth Tampa

Job Description


Description
"Registered Nurse Clinical Documentation Specialist Full Time Days" AdventHealth Tampa-work location will be Wesley Chapel


Location Address: AdventHealth Wesley Chapel-2600 Bruce B. Downs Blvd Wesley Chapel, Florida 33544

Work Hours/Shift:

Full Time

You will be responsible for:

  • Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient’s severity of illness and risk of mortality.
  • Assists in screening process, makes referrals, collaborates with Case Managers, ARNP’s, Physicians, and clinical nurse specialists to ensure continuity of patient care and validates clinical documentation with the plan of care.
  • Reviews clinical issues with coding staff as needed to ensure appropriate MSDRG. Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment.
  • Serves as Facilitator of the Clinical Documentation Improvement work group, Assists with special projects as needed & performs other duties as assigned.
  • Conducts initial and extended-stay concurrent reviews on all selected admissions for opportunities to clarify documentation in the medical record for accurate reflection of severity of illness, and documents findings, denoting all key information utilized in the tracking process.
  • Possesses in-depth knowledge of MSDRG payer issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures.
  • Identifies need to clarify documentation in records, and utilizes strong communication skills with physician, physician extender, case manager, nurse or other healthcare professionals, utilizing appropriate query tools to capture needed documentation. Conducts follow-up on unanswered queries during the patient stay, as needed, to obtain a response to open queries.
  • Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes, including POA – Present on Admission conditions and Core Measures.
  • Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
  • Reviews the progress of the concurrent documentation review program, through interpretation of process and operational reports, financial and compliance reports, and quality ratings reports. Able to identify areas of focus through report analysis.
  • Tracks response to Clinical Documentation and trends together with Coding/Medical Records.

     

Qualifications
What You Will Need:
  • Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrate excellent physician relations.
  • Able to organize and present information clearly and concisely; 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
  • Dependable, self-motivated and pleasant
  • Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills
  • Knowledge of pathophysiology, disease processes and treatments
  • Knowledge of regulatory environment
  • Strong ability to organize/triage work and manage multiple priorities at once
  • Minimum of five 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
  • Adventist Health Care online learning
  • Achieve a 70% or greater on JA Thomas Clinical Competency Pre-Assessment.
  • Knowledge of clinical documentation requirements that identify clinical conditions or procedures (Preferred)
  • Coding background (Preferred)
  • BSN, MSN (Preferred)
  • Clinical Documentation Specialist experience(Preferred)
  • CCDS (Certified Clinical Documentation Specialist) certification (Preferred)
Job Summary:

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 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.



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

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