Clinical Documentation Specialist

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.

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

Schedule:

Full time

Shift:

Day (United States of America)

Address:

501 REDMOND RD NW

City:

ROME

State:

Georgia

Postal Code:

30165

Job Description:

• Educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, and nursing staff.
• Communicates effectively with physicians and other healthcare providers to ensure appropriate, accurate, and complete clinical documentation. Collaborates with staff to resolve discrepancies with assignments and coding issues.
• Conducts well-timed follow-up case reviews on all concurrent cases, prioritizing those with clinical documentation clarifications.
• Participates in department meetings, providing feedback on outstanding issues and presenting educational opportunities.
• Maintains a 95% physician response rate to all valid clarifications.
• Reviews concurrent medical records for compliance, including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), and quality.
• Completes accurate and timely record reviews to ensure the integrity of documentation compliance. Inputs data accurately into CDI Software, resulting in precise metrics obtained through the reconciliation process.
• Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients, presenting opportunities for improved documentation compliance to clinical team members.
• Transcribes documentation clarifications as appropriate to ensure documentation compliance.
• Other duties as assigned.

Education:

• Bachelor's of Nursing [Preferred]

• Master's of Nursing [Preferred]

Field of Study:

• completed in health service administration, business administration, system performance engineering, industrial engineering, or public health

Work Experience:

• 5+ acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience. [Required]

• Clinical Documentation Specialist experience [Preferred]


Licenses and Certifications:

• Registered Nurse (RN) [Required] OR

• Physician Assistant (PA) [Required] OR

• Medical Doctor (MD) [Required] OR

• Certified Registered Nurse Practitioner (CRNP) [Required] OR

• Adult Acute Care Nurse Practitioner (ACNPC) [Required] OR

• Educational Commission for Foreign Medical Graduates (ECFMG) [Required]

• Certified Clinical Documentation Specialist (CCDS) [Preferred]

• Certified Documentation Improvement Practitioner (CDIP) [Preferred]

Pay Range:

$65,392.09 - $114,226.98

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