Clinical Document Integrity Specialist

Clinical Documentation Integrity Specialist

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

Benefits from Day One

Career Advancement

Whole Person Wellbeing Resources

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: FT M-F

Address: 60 Memorial Medical Parkway, Palm Coast, FL 32164

The community you’ll be caring for:

Flagler is a charming seaside community that is part of Florida’s Palm Coast. With a 19-mile stretch of white sand beaches, it’s known as an ideal setting for a variety of watersports and recreational activities. When you’re in the mood for something relaxing, you can stroll through a secluded nature preserve on one of the area’s many biking and walking paths, including the Great Florida Birding Trail, or visit the Intracoastal Waterway, a unique alternative to the ocean. From saltwater fishing to deep sea diving, sprawling golf courses to oceanfront restaurants, you’ll have plenty of ways to spend your free time and enjoy the warm weather. With all this right in your backyard, Palm Coast truly has something for each of our employees and their families.

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, care management and etc… 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.

• Demonstrates competence in chart audits

• Correctly identifies physician clarification opportunities

• Proficient in formulating valid clarifications that are easily understood by physicians and other members of the medical team.

• Accurately reconciles all cases in CDI database.

• Maintains a 95% physician response rate to all valid clarifications.

The expertise and experiences you’ll need to succeed :

Minimum qualifications :

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

• A physician who has graduated from a medical school that is listed in the World Directory of Medical Schools ( World Directory

• Current active State license as a Registered Nurse, MD/DO, 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).

• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations.

• Knowledge of pathophysiology, disease processes and treatments.

Preferred qualifications:

• BSN or Higher in a healthcare related field

• CCDS (Certified Clinical Documentation Specialist) certification or/and

• CDIP (Certified Documentation Improvement Practitioner) certification

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

Category: Case Management

Organization: AdventHealth Palm Coast

Schedule: Full-time

Shift: 1 – Day

Req ID: 24035557

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.