Schedule: Full time
Shift:Day (United States of America)
Address:9100 W 74TH ST
City:SHAWNEE MISSION
State:Kansas
Postal Code:66204
Job Description:Clinical Document Specialist II - Full-TimeLocation: AdventHealth Shawnee Mission
Schedule:Full-Time |
Day ShiftJob SummaryResponsible for facilitating and obtaining accurate, complete, and compliant physician documentation to support the severity of illness, risk of mortality, quality outcomes, and complexity of patient care. Educates physicians, advanced practice providers, nursing staff, care management, and other healthcare professionals regarding documentation standards, regulatory requirements, and clinical documentation improvement (CDI) practices. Ensures adherence to organizational policies, regulatory guidelines, departmental goals, and performance standards while promoting documentation integrity and compliance. Contributes to the efficiency and effectiveness of clinical documentation processes through collaboration, critical thinking, and continuous improvement efforts.
Essential Functions- Facilitates clinical documentation improvement activities to ensure accurate representation of patient acuity, severity of illness, risk of mortality, and quality outcomes.
- Reviews concurrent medical records for completeness, accuracy, compliance, and documentation opportunities.
- Identifies opportunities for documentation improvement through analysis of clinical indicators, medical necessity, and patient care documentation.
- Develops and communicates clinically supported documentation clarifications to physicians, advanced practice providers, and other members of the healthcare team.
- Initiates and formulates CDI severity worksheets and documentation queries that support compliant documentation practices.
- Reviews and reconciles documentation related to severity of illness (SOI), risk of mortality (ROM), patient safety indicators (PSI), hospital-acquired conditions (HAC), hierarchical condition categories (HCC), and other quality measures.
- Accurately enters and maintains CDI data within designated software systems, supporting reporting and performance metrics.
- Collaborates with physicians, nursing staff, HIM professionals, coders, and other healthcare team members to improve documentation quality and accuracy.
- Works with Health Information Management staff to resolve DRG assignment discrepancies and coding-related documentation issues.
- Conducts timely follow-up reviews on concurrent cases and prioritizes cases requiring clarification resolution.
- Educates physicians, advanced practice providers, nursing staff, and other healthcare professionals regarding documentation requirements, regulatory guidelines, and best practices.
- Maintains physician engagement and supports timely responses to documentation clarification requests.
- Participates in departmental meetings, educational initiatives, performance improvement activities, and process improvement efforts.
- Assists with orientation, training, mentoring, and precepting of new team members.
- Completes annual educational projects and presentations for the CDI team.
- Maintains documentation integrity and compliance with organizational, regulatory, and accreditation requirements.
- Performs other duties as assigned.
Knowledge, Skills, and Abilities- Excellent verbal and written communication skills with the ability to develop and maintain effective professional relationships.
- Demonstrated ability to communicate effectively with physicians, advanced practice providers, and interdisciplinary healthcare teams.
- Strong organizational, prioritization, and time management skills.
- Ability to manage multiple responsibilities and competing priorities in a fast-paced healthcare environment.
- Proficiency in computer applications, electronic health record systems, CDI software, and related technologies.
- Ability to work effectively with multiple software applications simultaneously.
- Strong critical thinking, clinical reasoning, problem-solving, and decision-making skills.
- Ability to analyze clinical documentation and identify opportunities for improvement.
- Knowledge of pathophysiology, disease processes, clinical treatment modalities, and patient care practices.
- Knowledge of clinical documentation improvement principles and documentation requirements.
- Knowledge of coding concepts, DRG methodology, reimbursement systems, and healthcare quality measures.
- Knowledge of regulatory, compliance, accreditation, and quality reporting requirements.
- Ability to organize, interpret, and present information clearly and concisely.
- Demonstrated ability to learn, develop, and refine clinical documentation improvement skills.
- Dependable, self-motivated, professional, and collaborative.
- Ability to work independently while maintaining strong teamwork and customer service standards.
Education- Associate's Degree required.
Field of Study- Nursing or a health-related field.
Work Experience- Four years of acute care nursing experience with medical-surgical, critical care, post-acute care, or emergency department experience required.
- Two years of Clinical Documentation Improvement (CDI) experience required.
- Licenses and Certifications
- Current and active Registered Nurse (RN), Physician Assistant (PA), Certified Registered Nurse Practitioner (CRNP), Advanced Practice Registered Nurse (APRN), Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), or Educational Commission for Foreign Medical Graduates (ECFMG) credential required.
- Certified Clinical Documentation Specialist (CCDS) required.
- JATA training preferred.
Additional Information- Candidates may qualify if they are an unlicensed physician who graduated from a medical school listed in the World Directory of Medical Schools and meet eligibility requirements for ECFMG Certification.
Physical Requirements: (Please click the link below to view work requirements)
Physical Requirements - https://tinyurl.com/23km2677
Pay Range:$66,999.24 - $124,618.59
