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Clinical Documentation Specialist
AdventHealth
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Details

Posted: 31-Jul-22

Location: Tampa, Florida

Salary: Open

Categories:

Quality/Risk Management

Internal Number: 22026934


Description

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

  • Benefits from Day One
  • Paid Days Off from Day One
  • Student Loan Repayment Program
  • Whole Person Wellbeing Resources
  • Debt-free Education* (Certifications and Degrees without out-of-pocket tuition expense)
  • Nursing Clinical Ladder Program*
  • Sign-on Bonus*
  • Relocation Bonus*
  • Team Based Nursing Model*
  • Reimbursement for the NCLEX*

* Nursing or BU specific benefits and perks

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: Full Time

Shift: Day Shift, Hybrid position 2-3 days/week working from Heart of Florida Hospital and the remaining days working remote

Location: 40100 US-27, Davenport, FL 33837

The community you’ll be caring for: AdventHealth Heart of Florida  

  • AdventHealth Heart of Florida is a licensed 193-bed acute care hospital, coupled with outpatient services including imaging, rehab, lab and wound care, that has been serving the community for over 50 years.
  • As a part of the AdventHealth network patients will have greater access to a wide range of innovative therapies, new research, leading-edge technology and an extensive team of medical specialists.
  • High-quality care that has been recognized by the Joint Commission, the American Heart Association and the American Diabetes Association.
  • Located in Davenport, FL., which is close to major destinations, like Busch Gardens, Legoland, and Walt Disney World, without being located in the central hub of tourism.

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:

  • Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs and HACs to ensure documentation compliance is accomplished.
  • Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, nursing, and collaboration with the healthcare team.  This includes quarterly and annual compliance updates from Medicare.
  • Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation.  Communicates with HIM staff and collaborates with them to resolves discrepancies with DRG assignments and other coding issues.
  • Completes well-timed follow-up case reviews on all concurrent cases with priority given for resolution of those with clinical documentation clarifications.
  • Participates in department meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified by the CDI leaders.
Qualifications

The expertise and experiences you’ll need to succeed:

Minimum qualifications:

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

Preferred qualifications: 

  • BSN or MSN
  • CDS Experience

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

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About AdventHealth
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.
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