Clinical Documentation Specialist I FT Days at AdventHealth

Date Posted: 11/29/2021


Job Snapshot

  • Job Schedule
  • Location:
    Tavares, FL
  • Date Posted:
  • Job ID:
  • Job Family
  • Shift
    1 - Day

Job Description


Clinical Documentation Specialist FT Days - Up to $3K Sign on Bonus and $3K Relocation Bonus Available

Location Address: 1000 Waterman Way Tavares, Florida 32778


Top Reasons to Work at AdventHealth Waterman

  • Career Growth and Advancement Potential
  • Join a Faith Based, Non-Profit Healthcare Organization
  • Community Based Hospital Focused on Patient Care

Work Hours/Shift:


$3K Sign-on Bonus and $3K Relocation available for eligible candidates (See Terms Below)

Sign-on Eligibility:

  • Applicable experience required
  • Full Time employment contract required
  • Rehires within 12 months are not eligible
  • Internal candidates are not eligible

Relocation Eligibility:

  • Applicable experience required
  • Full Time employment contract required
  • Rehires within 12 months are not eligible.
  • Must live 50 miles outside of campus address.

You Will Be Responsible For:

  • Performs accurate and timely review of electronic health record to initiate work sheets on DRG payers for inpatient admissions. 
  • Demonstrates the ability to analyze and identify areas of potential gaps representing opportunities for documentation improvement in order to reflect severity/complexity profile making an appropriate determination whether a physician clarification/query is required.
  • Possess the ability to formulate clinically credible documentation/ clarifications/queries; utilizing effective and appropriate communication options for physician follow up, which will occur in a timely manner.
  • Identifies the need and presence of “MCC” or “CC” for the DRG
  • Demonstrates efficiency in Guide (JATA) guidelines, software and accurate input of data into CDMP Trak.  As well as, the ability to review archived cases and generate reports as needed.
  • Requires knowledge of Medicare Part A as well as regulatory requirements that will be demonstrated by appropriate assignment of principal diagnosis and surgical procedure(s).
  • Clinical reviews and concurrent code assignment performed by CDS will demonstrate understanding of requirements and guidelines in accordance with AHA (American Hospital Association) Coding Clinics.
  • Possession of analytical based concepts, critical thinking, problem solving and deductive reasoning skills in regards to patient health assessment and disease entities shall be evidenced in achievement of optimum DRG assignment.
  • Excellence of interpersonal and communication skills will be evidenced through interaction with HIM staff (coders) in resolution of discrepancies.
  • Department improvement shall be demonstrated through participation in the development and implementation of plans for education of physicians, nursing and ancillary staff.
  • Computer proficiency will be demonstrated and maintained to perform/complete work assignments including but not limited to the electronic medical record, Guide, Optum coding software, Internet Explorer, MicroSoft Word/Power Point/Excel, Outlook email/calendar management. 
  • Assists with special projects as needed.

What You Will Need:

  • Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication as well as strong interpersonal skills.
  • Knowledge of Pathophysiology and disease process
  • Working expertise in the use of Microsoft Word, Power-Point and Excel programs. 
  • Proficient typing skills with the ability to accurately type >35 words per minute.
  • R.N. – registered nurse
  • Minimum 5 years of recent hospital experience
  • BSN preferred
  • ICU, CCU, or strong Med/Surg. Experience preferred.  
  • Utilization Review or coding experience preferred
  • State of Florida Registered Nursing License
  • BSN or MA preferred
  • CCDS – Certified clinical documentation specialist.

Job Summary:

The CDS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness.  This involves extensive record review, interaction with physicians, HIM professionals and nursing staff.   Active participation in team meetings and education of staff in the CDMP® process is a key role

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

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