* 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.
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.
What Will You Need:
EDUCATION AND EXPERIENCE REQUIRED:
Four - five years of acute care experience in med/surg, critical care, emergency room, or PACU
EDUCATION AND EXPERIENCE PREFERRED :
Minimum of one year as a Clinical Documentation Specialist
LICENSURE, CERTIFICATION, OR REGISTRATION REQUIRED:
Current active Florida State license as a Nurse Practitioner, or Physician's Assistant
LICENSURE, CERTIFICATION, OR REGISTRATION PREFERRED :
Certified Clinical Documentation Specialist (issued by the Association for Clinical
Documentation Improvement Specialists (ACDIS))
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.
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.
AdventHealth Greater Orlando (formerly Florida Hospital) is one of the largest faith-based health care providers in the United States. For 150 years, we have carried on a tradition of providing whole-person care that not only addresses patients' physical ailments, but also supports their emotional and spiritual well-being. We demonstrate the same level of compassion and care for our employees as well, doing all that we can to help them realize their full potential – both personally and professionally.