Clinical Documentation Specialist - Ocala at AdventHealth

Date Posted: 10/17/2020

Job Snapshot

  • Job Schedule
    Full-Time
  • Location:
    Tampa, FL
  • Date Posted:
    10/17/2020
  • Job ID:
    20021438
  • Job Family
    Quality/Clinical Effectiveness
  • Travel
    Yes, 25 % of the Time
  • Shift
    1 - Day

Job Description


Description

Clinical Documentation Information Specialist AdventHealth Ocala

Location Address: 1500 SW 1st Ave Ocala, Florida 34471

Top Reasons To Work At AdventHealth Ocala
  • Horse Capital of the World
  • Driving distance to Gainesville, St. Augustine, Orlando, Tampa, Sarasota

  • Part of the community since 1898, providing healthcare to Marion County for over 120 years

  • Florida Hospital Ocala offers a broad spectrum of services, with programs that are nationally recognized and accredited

  • Spectacular springs throughout the county
 

Work Hours/Shift:

  • Full Time
 
  • Demonstrates our mission of 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 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 CDI Software resulting in accurate metrics obtained through the reconciliation process.  Understands and supports CDI documentation strategies (upon completion of didactic training) and continues to educate self and team members, by attending monthly mandated education sessions and 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 quality considerations in balance with regulatory compliance.  Initiates/formulates CDI severity worksheets and clinically credible clarifications for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other clinical team members.
  • Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs and HACs to ensure documentation compliance is accomplished.
Qualifications

What Will You Need:        

EDUCATION AND EXPERIENCE REQUIRED:
  • Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
EDUCATION AND EXPERIENCE PREFERRED
  • Clinical Documentation Specialist experience
  • BSN,MS
LICENSURE, CERTIFICATION OR REGISTRATION 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.
LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:
  • CCDS (Certified Clinical Documentation Specialist) certification
  • CDIP (Certified Documentation Improvement Practitioner) certification
 
 
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 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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