Clinical Document Spec II Orlando, FL

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

• Benefits from Day One

• Paid Days Off from Day One

• Career Development

• Whole Person Wellbeing Resources

• Mental Health Resources and Support

Schedule: Full Time

Shift : Days

Location: 601 East Rollins Street Orlando, FL 32803

The community you'll be caring for: AdventHealth Orlando

• Located on a lush tropical campus, our flagship hospital, 1,368-bed AdventHealth Orlando

• Serves as the major tertiary facility for much of the Southeast, the Caribbean and South America

• AdventHealth Orlando houses one of the largest Emergency Departments and largest cardiac catheterization labs in the country

• We are already one of the busiest hospitals in the nation, providing service excellence to more than 32,000 inpatients and 125,000 outpatients each year

The role you'll contribute:

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.

The value you'll bring to the team:

• Demonstrates 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.

• 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 Webinars.

Qualifications

The expertise and experiences you'll need to succeed:

• Bachelor's BSN

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

• 3 of Clinical Documentation Specialist experience

• RN - Registered Nurse - State Licensure and/or Compact State Licensure

• NPC - Certified Nurse Practitioner

• PA - Physician 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.

• CDIP - Clinical Documentation Improvement Professional CDIP (Certified Documentation Improvement Practitioner) certification, in lieu of BSN and 3 years of experience

• CDS (Certified Clinical Documentation Specialist) certification, in lieu of BSN and 3 years of experience

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

Category: Case Management

Organization: AdventHealth Winter Garden

Schedule: Full-time

Shift: 1 - Day

Req ID: 25021014

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.