Registered Nurse Clinical Doc Specialist at AdventHealth

Date Posted: 12/2/2019

Job Snapshot

  • Job Schedule
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Family
    Case Management
  • Travel
  • Shift
    1 - Day
  • Application Zone
    1-Shared Services
  • Organization
    AdventHealth New Smyrna Beach

Job Description

Registered Nurse Clinical Doc Specialist AdventHealth New Smyrna Beach
Location Address: 401 Palmetto Street, New Smyrna, Florida 32168
Top Reasons To Work At AdventHealth New Smyrna Beach
Immediate Health Insurance Coverage

Great benefits such as: Educational Reimbursement

Career growth and advancement potential

High quality of life with low cost of living on the shores of New Smyrna Beach.

Work Hours/Shift:
Full Time / Day

You Will Be Responsible For:
  • The Clinical Documentation Specialist will be responsible for conducting clinically based current and retrospective reviews of inpatient medical records to evaluate the clinical documentation of clinical services.
  • Identify and clarify missing, conflicting, or nonspecific physician documentation related to diagnoses and procedures.
  • Support accurate diagnostic and procedural coding, DRG assignment, severity of illness, and expected risk of mortality, leading to appropriate reimbursement.
  • Proactively solicits clarification from physicians when further specificity is needed in the documentation, and consults with attending physician when conflicting information appears in the medical record.
  • Completes initial reviews for a specified patient population to a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness; and b) initiate a review worksheet. Conducts follow-up reviews of patients to support and assign a working or final DRG assignment upon patient discharge, as necessary. Demonstrates clinical knowledge skills/abilities for the patient population served.
  • Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
  • Communicates with the coding professionals as needed by phone or email to ensure accuracy of diagnosis and procedural data for appropriate DRG assignment.                         
  • Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to identify potential opportunities for documentation improvement or clarification.
  • Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health care record. The education is based on Centers for Medicare and Medicaid Services (CMS) documentation guidelines, current coding guidelines, and AHA Coding Clinics.
  • Demonstrates knowledgeable working expertise in the use of CDMP Software program, Cerner, Microsoft Word, Microsoft PowerPoint, Microsoft Excel program, and the Internet.
  • Tracks responses to CDMP; trends/tracks compliance. Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
  • Responsible for adhering to the hospital Corporate Compliance plan, Policies and Procedures and to the rules and regulations of all local, state and Federal agencies and to the standards of all accrediting bodies.


What you will need:
  • Graduate of an approved school of nursing. 
  • Bachelor’s Degree in Nursing or other field of study. Current registration and license with state board of examiners.  
  • BLS certification 
  • Demonstrates the ability to apply to a high degree abstract reasoning, technical skills and abilities to the patient care setting and ancillary departments.
  • A minimum of five years of nursing experience within the acute care setting and strong verbal and written communication skills.
  • Is a graduate of an approved school of Nursing. Current registration and license with state board of   examiners and holds a Florida RN License. Current certification in basic life support required
  • Clinical knowledge of payment systems and methodologies, ICD-9 and ICD-10 coding concepts and guidelines, coding guidelines, AHA coding clinics, and healthcare regulatory compliance.
  • Must be able to operate the following equipment in a competent and responsible manner: Computer system, Clinical Documentation software, Cerner, and other hospital-based programs, printer, telephone, copier, and fax machine. Knowledge of computer applications, including but not limited to: Microsoft Windows, Outlook, Excel, and Word. 
  • Clinical knowledge of payment systems and methodologies, ICD-9 and ICD-10 coding concepts and guidelines, healthcare regulatory compliance.
  • A knowledge base of working DRG assignment and Medicare and Medicaid regulations as related to inpatient coding.

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

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