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

·Paid Days Off from Day One

·Student Loan Repayment Program

·Career Development

·Whole Person Wellbeing Resources

·Mental Health Resources and Support

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.

Schedule: Full Time

Shift : Days

The commun ity you’ll be caring for: AdventHealth Division

·AdventHealth Pepin Heart Institute, known across the country for its advances in cardiovascular disease prevention, diagnosis, treatment and research.

·Surgical Pioneers – the first in Tampa with the latest robotics in spine surgery

·Building a brand new, six story surgical and patient care tower which will ensure state of the art medical and surgical car for generations to come

·Awarded the Get With The Guidelines – Stroke GOLD Quality Achievement Award from the American Heart Association/American Stroke Association and have been recognized as a recipient of their Target: Stroke Honor Roll for our expertise in stroke care. We have also received certification by The Joint Commission in collaboration with the American Stroke Association as a Primary Stroke Center.

The ro le you’ll contribute:

Under general supervision of the Director of Clinical Documentation Integrity and in some situations the supervision of the Clinical Documentation Integrity Manager, and in collaboration with physicians, nursing and HIM coders, the Clinical Documentation Auditor strategically facilitates and obtain 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. The Clinical Documentation Auditor educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, care management and quality abstracters. The Clinical Documentation Auditor 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

The val ue you’ll bring to the team:

· Reviews concurrent and retrospective medical record for documentation compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), and quality.

· Completes accurate and timely record review to ensure the integrity of documentation compliance.

· Completes accurate and concise input of data into CDI Software.

· Understands and supports CDI documentation strategies (upon completion of didactic training) and continues to educate self and team members, by attending monthly mandated education sessions and using educational tools, videos and provided Webinars

· Conducts audits for quality including, but not limited to deceased second level reviews, focused disease process reviews as needed, patient safety indicators, CDI team audits. Collects data, analyzes data and reports data to CDI Leadership team.

· Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping quality considerations in balance with regulatory compliance. Initiates/formulates CDI severity worksheets and clinically credible clarifications for inpatients, sending/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 is accomplished.

· Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including quarterly and annual compliance updates from Medicare.

· Effectively and appropriately communicates with physicians and other healthcare providers as needed to ensure appropriate, accurate and complete clinical documentation. Communicates with HIM staff and collaborates with them to resolves discrepancies with DRG assignments and other coding issues.

· Participates in department meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified by the CDI leaders.

· Assumes personal responsibility for professional growth, development, and continuing education to maintain a high level of proficiency.

Qualifications

T he expertise and experiences you’ll need to succeed:

· Bachelor's Degree of Science in Nursing and 3 years of Clinical Documentation Integrity Specialist experience OR 4 years of recent Clinical Documentation Specialist experience Required

· 5 Acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience Required

· 4 of recent Clinical Documentation Specialist experience Required

· Current active State license as a Registered Nurse, Nurse Practitioner, Physician’s Assistant, Medical Physician, or an unlicensed Educational Commission for Foreign Medical Graduates (ECFMG) certified physician who has graduated from a medical school that is listed in the World Directory of Medical Schools (World Directory) Required.

· CCDS (Certified Clinical Documentation Specialist) certification or CDIP (Certified Documentation Improvement Practitioner) certification and 2 years Clinical Documentation Integrity experience Required

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

Category: Quality/Clinical Effectiveness

Organization: AdventHealth Tampa

Schedule: Full-time

Shift: 1 - Day

Req ID: 25007780

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.