Clinical Documentation Specialist – Clinical Documentation Improvement – Orlando

  • Adventist Health System
  • Orlando, FL, USA
  • Jan 12, 2018

Job Description

Clinical Documentation Specialist - Clinical Documentation Improvement - Orlando
Florida Hospital seeks to hire a Clinical Documentation Specialist who will embrace our mission to extend the healing ministry of Christ.

Facility Profile:
Located on a lush tropical campus, our flagship hospital, 1,107-bed Florida Hospital Orlando, serves as the major tertiary facility for much of the Southeast, the Caribbean and South America. Florida Hospital 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.

Work Hours/Shifts:
Monday - Friday, 8am - 5pm

5,000 Sign-on Bonus available for eligible candidates (see terms below)

Job Summary:
Under general supervision of the Director of Clinical Documentation Improvement and more closely the supervision of the Clinical Documentation Improvement 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, and to support ICD-10 implementation. The CDS educates members of the patient care team regarding documentation guidelines, including attending 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.

Knowledge, Skills, Education, & Experience Required:
  • Ability to learn/develop and fine-tune the skills necessary to perform Clinical Documentation Management
  • Organizational, analytical, writing and interpersonal skills
  • Dependable, self-motivated and pleasant
  • Critical-thinking, problem-solving and deductive-reasoning skills
  • Knowledge of Pathophysiology, disease process and treatments
  • Basic computer skills - familiarity with Windows-based software programs
  • Knowledge of regulatory environment
  • Strong interpersonal skills
  • Strong ability to organize/triage work and manage multiple priorities at once
  • Four - five years of acute care experience in med/surg, critical care, emergency room, or PACU
  • Knowledge of clinical documentation requirements that identify clinical conditions or procedures to support and enhance ICD-9 and ICD-10 coding. (Preferred)
  • BSN, MSN (Preferred)
  • Minimum of one year as a Clinical Documentation Specialist (Preferred)

Licensure, Certification, or Registration Required:
  • Current active Florida State license as a Registered Nurse, Nurse Practitioner, or Physician's Assistant
  • Certified Clinical Documentation Specialist (issued by the Association for Clinical Documentation Improvement Specialists (ACDIS)) (preferred)

Job Responsibilities:
Demonstrates through behavior Florida Hospital's Core Values of Integrity, Compassion, Balance, Excellence, Stewardship and Teamwork as outlined in the organization's Performance Excellence Program
  • Reviews concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies.
  • Develop an active, collaborative interface and structure with Florida Hospital Medical Staff
  • Completes accurate and timely record review to ensure the integrity of documentation compliance. Completes accurate and concise input of data into CDMP Trak resulting in accurate metrics provided by the CDMP program. Understands and supports CDMP documentation strategies (upon completion of training) and continues to educate self and team members using educational tools, videos and provided WebEx's.
  • Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping reimbursement considerations in balance with regulatory compliance. Initiates/formulates CDMP severity worksheets and clinically credible clarifications for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other medical staff.
  • Transcribes documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety to ensure documentation compliance is accomplished.
  • Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including attending physicians, allied health practitioners, nursing, and care management. This includes quarterly 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 Task Force meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified by the CDI group.
  • Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.
  • Performs other duties as assigned.

If you want to be a part of a team that is dedicated to delivering the highest quality in patient care, we invite you to explore the Clinical Specialist opportunity with Florida Hospital and apply online today.

*Bonus Details:
  • Applicable experience required.
  • Must live 50 or more miles from 601 East Rollins Dr., Orlando, FL to qualify.
  • Full Time employment contract required.
  • Rehires within 12 months are not eligible.

Job Keywords:
Clinical, Specialist, Documentation Improvement, East Orlando