Registered Nurse Clinical Documentation Specialist Full Time Days AdventHealth Tampa
Location Address: 3100 E Fletcher Ave, Tampa FL 33613
Work Hours/Shift: Full Time Days
You will be responsible for:
Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patientâ™s severity of illness and risk of mortality.
Assists in screening process, makes referrals, collaborates with Case Managers, ARNPâ™s, Physicians, and clinical nurse specialists to ensure continuity of patient care and validates clinical documentation with the plan of care.
Reviews clinical issues with coding staff as needed to ensure appropriate MSDRG. Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment.
Serves as Facilitator of the Clinical Documentation Improvement work group, Assists with special projects as needed & performs other duties as assigned.
Conducts initial and extended-stay concurrent reviews on all selected admissions for opportunities to clarify documentation in the medical record for accurate reflection of severity of illness, and documents findings, denoting all key information utilized in the tracking process.
Possesses in-depth knowledge of MSDRG payer issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures.
Identifies need to clarify documentation in records, and utilizes strong communication skills with physician, physician extender, case manager, nurse or other healthcare professionals, utilizing appropriate query tools to capture needed documentation. Conducts follow-up on unanswered queries during the patient stay, as needed, to obtain a response to open queries.
Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes, including POA â“ Present on Admission conditions and Core Measures.
Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
Reviews the progress of the concurrent documentation review program, through interpretation of process and operational reports, financial and compliance reports, and quality ratings reports. Able to identify areas of focus through report analysis.
Tracks response to Clinical Documentation and trends together with Coding/Medical Records.
What You Will Need:
Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrate excellent physician relations.
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.
Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist
Dependable, self-motivated and pleasant
Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills
Knowledge of pathophysiology, disease processes and treatments
Knowledge of regulatory environment
Strong ability to organize/triage work and manage multiple priorities at once
Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience
Current active State license as a Registered Nurse
Adventist Health Care online learning
Achieve a 70% or greater on JA Thomas Clinical Competency Pre-Assessment.
Knowledge of clinical documentation requirements that identify clinical conditions or procedures (Preferred)
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 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. 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.
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.
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