Clinical Documentation Specialist II

Our promise to you:

Joining Advent Health 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. Advent Health 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.

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

• Benefits from Day One:
  Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance

• Paid Time Off from Day One

• 403-B Retirement Plan

• 4 Weeks 100% Paid Parental Leave

• Career Development

• Whole Person Well-being Resources

• Mental Health Resources and Support

• Pet Benefits

Full time

Day (United States of America)

2450 N ORANGE BLOSSOM TRL

KISSIMMEE

Florida

34744

Up to $7,500.00 Sign On Bonus

Shift Information:
Monday to Friday, 40 hrs – Flexible hours may be between 6:00 a.m. – 6:30 p.m

Location - Fully Virtual

Responsible for facilitating and obtaining quality physician documentation for clinical conditions and procedures to support the severity of illness, risk of mortality, and complexity of patient care. This position educates the patient care team, including physicians, allied health practitioners, nursing, and care management, on documentation guidelines. In addition, this position ensures adherence to departmental and organizational goals, standards of performance, and policies and procedures.

Additionally, this role continually ensures quality documentation and regulatory compliance. Responsibilities for this role include actively participating in customer service and maintaining respectful relationships with all team members. This role contributes to the overall efficiency and effectiveness of clinical documentation processes.

• Inputs data into CDI Software accurately and concisely, resulting in precise metrics obtained through the reconciliation process.
• Recognizes opportunities for documentation improvement using strong critical-thinking skills.
• Uses critical thinking and sound judgment in decision-making, balancing quality considerations with regulatory compliance.
• Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients, presenting opportunities for improved documentation compliance to physicians, nurse practitioners, and other clinical team members.
• Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs, and HACs to ensure documentation compliance.
• Educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, nursing, and collaboration with the healthcare team.
• Communicates effectively and appropriately with physicians and other healthcare providers to ensure accurate and complete clinical documentation.
• Collaborates with HIM staff to resolve discrepancies with DRG assignments and other coding issues.
• Completes well-timed follow-up case reviews on all concurrent cases, prioritizing resolution of those with clinical documentation clarifications.
• Participates in department meetings, providing feedback on outstanding issues, presentations for educational opportunities, and other needs identified by CDI leaders.
• Maintains a 98% physician response rate to all valid clarifications.
• Assists in new hire orientation through precepting and mentoring.
• Completion of educational project to be presented to CDI team yearly.
• Completes accurate and timely record reviews to ensure the integrity of documentation compliance.
• Reviews concurrent medical records for compliance, completeness, and accuracy regarding severity of illness, risk of mortality, and quality.
• Performs other duties as assigned.

• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations. [Required]
• Able to organize and present information clearly and concisely;…