Clinical Documentation Auditor 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: Remote

The role you'll contribute:

The Clinical Documentation Integrity Manager is a Registered Nurse and/or a Registered Health Information Administrator with a high level of clinical proficiency necessary for the oversight of the Clinical Documentation team which is comprised of registered nurses and clinical documentation specialists. This role will oversee the review processes of complex patients that vary in age and have different developments in the acute and chronic disease states. Must have proven leadership and management skills that will promote effective and efficient review of physician documentation that supports the patient's level of care and develop action plans for improvement. Must have knowledge and job experience in management of processes, system implementations, and project management. The Manager of Clinical Documentation works to strategically plan, organize, implement and evaluate the Compliant Documentation Management Program (CDMP) at AdventHealth. This includes management of the case mix index (CMI), length of stay (LOS), severity of illness (SOI) and risk of mortality (ROM) in cooperation with the Director of Clinical Documentation Improvement and all other operational hospital departments. The manager manages the Clinical Documentation Specialists (CDSs) in planning, implementing improvements, and re-evaluating processes to keep staff engaged and to assist in meeting department goals. This role will oversee the review processes of complex patients that vary in age and have different developments in the acute and chronic disease states. Must have proven leadership and management skills that will promote effective and efficient review of physician documentation that supports the patient's level of care and develop action plans for improvement. Must have knowledge and job experience in management of processes, system implementations, and project management. The Clinical Documentation Manager will report directly to the Regional Clinical Documentation Director and will work extensively with CDI teams, physicians, Chief Medical Officers and Chief Nursing Officers of the current 6 hospitals in the North Florida Division in a matrix relationship to coordinate the efficient review and documentation capture of the underlying conditions that are supported by the physicians' secondary review of the patient record, upon request of the clinical documentation team members. Develops, assesses, plans, implements, and evaluates procedures and processes for the system, offers continuing education, process improvement, and change management. Is actively involved in future planning and strategic development for system CDI needs, to include policy development, program development, ongoing audits for the system level and campus level, and quality improvement efforts. Works under general supervision and utilizes critical thinking skills. 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:

• Reviews concurrent and retrospective medical record for documentation 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.

• 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

• Conducts audits for quality including, but not limited to deceased second level reviews, focused disease process reviews as needed, patient safety indicators, CDI team audits. Collects data, analyzes data and reports data to CDI Leadership team.

Qualifications

The expertise and experiences you'll need to succeed:

• Work Experience 5 Acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience Required 4 of recent Clinical Documentation Specialist experience Required 1 of Second Level Review CDIS experience Preferred 5 CDI experience Preferred

• Additional Licenses and Certifications Current active State license as a Registered Nurse, Nurse Practitioner, Physicians Assistant, Medical Physician, or an unlicensed Educational Commission for Foreign Medical Graduates (ECFMG) certified physician who has graduated from a medical school that is listed in the World Directory of Medical Schools (World Directory) Required CCDS (Certified Clinical Documentation Specialist) certification or CDIP (Certified Documentation Improvement Practitioner) certification and 2 years Clinical Documentation Integrity experience Required

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

Category: Quality/Clinical Effectiveness

Organization: AdventHealth Orlando

Schedule: Full-time

Shift: 1 - Day

Req ID: 25024248

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.