5-7 years of acute care nursing experience in medical/surgical, intensive care, post-acute care, or emergency department settings.
Associates degree in nursing or a health-related field.
Registered Nurse (RN), Physician Assistant (PA), Certified Registered Nurse Practitioner (CRNP), Advanced Practice Registered Nurse (APRN), Medical Doctor (MD), or Doctor of Osteopathic Medicine (DO) license required.
Knowledge of pathophysiology, disease processes, and treatments.
Strong critical-thinking and problem-solving skills.
Ability to manage multiple priorities and organize work effectively.
Educate patient-care team members on documentation regulations and guidelines.
Communicate with healthcare providers to ensure accurate clinical documentation.
Collaborate with staff to resolve coding discrepancies.
Conduct follow-up case reviews on concurrent cases for documentation clarifications.
Participate in department meetings to provide feedback and educational opportunities.
Maintain a 95% physician response rate for documentation clarifications.
Review medical records for compliance and accuracy.
Benefits
Comprehensive health insurance options.
Retirement savings plan with employer matching.
Paid time off and holidays.
Continuing education opportunities.
Supportive work environment with a focus on professional development.
Full Job Description
Schedule: Full time
Shift: Day (United States of America)
Address: 3100 E FLETCHER AVE
City: TAMPA
State: Florida
Postal Code: 33613
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.
Knowledge, Skills, and Abilities:
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; excellent computer and keyboarding skills; ability to use multiple software programs simultaneously; high degree of prioritization skills [Required]
Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist [Required]
Dependable, self-motivated and pleasant [Required]
Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills [Required]
Knowledge of pathophysiology, disease processes and treatments [Required]
Strong ability to organize/triage work and manage multiple priorities at once [Required]
Knowledge of clinical documentation requirements that identify clinical conditions or procedures [Preferred]
Coding background [Preferred]
Knowledge of quality guidelines [Preferred]
Education:
Associates [Required]
Field of Study:
in nursing or health related field
Work Experience:
4+ acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience [Required]
Candidate may be an unlicensed physician who graduated from a medical school listed in the World Directory of Medical Schools AND meets eligibility requirements to apply for the ECFMG Certification.
Licenses and Certifications:
Registered Nurse (RN) [Required] OR Physician Assistant (PA) [Required] OR Certified Registered Nurse Practitioner (CRNP) [Required] OR Advanced Practice Registered Nurse (APRN) [Required] OR Medical Doctor (MD) [Required] OR Doctor of Osteopathic Medicine (DO) [Required] OR Educational Commission for Foreign Medical Graduates (ECFMG) [Required]
Physical Requirements: (Please click the link below to view work requirements) Physical Requirements - https://tinyurl.com/23km2677
Pay Range:
$66,830.40 - $124,300.80
About AdventHealth University
AdventHealth University is a private university in Orlando, Florida. It was founded in 1992 and is affiliated with the Seventh-day Adventist Church. The university offers undergraduate and graduate degree programs in various fields including nursing, radiography, and sonography. AdventHealth University is accredited by the Southern Association of Colleges and Schools Commission on Colleges.
