System Retrospect Cds I Remote - Altamonte Springs, United States - AdventHealth Corporate
Description
AdventHealth Corporate
All the benefits and perks you need for you and your family:
- Benefits from Day One
- 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 thattogether we are even better.
Shift :
Full-time; Monday - Friday
Job Location :
Remote
The role 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 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 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.The value that you bring to the team:
- Demonstrates extending the healing ministry of Christ, through behavioral whole care standards of
- every action taken. Guided by relentless stewardship in the management of resources entrusted to them.
- Reviews concurrent 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 resulting in accurate metrics obtained through the reconciliation process. 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
- Recognizes opportunities for documentation improvement using strong criticalthinking 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 patientcare team regarding documentation regulations and guidelines, including physicians, allied health practitioners, nursing, and collaboration with the healthcare team. This includes quarterly and annual compliance updates from Medicare.
- Effectively and appropriately communicates with physicians and other healthcare providers as necessary 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.
The expertise and experiences you'll need to succeed:
- Associate and 5 years experience
- 5 years acute care
- Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, postacute care unit, or Emergency Department experience.
- 3 years of Clinical Documentation Specialist experience
- CCDS (Certified Clinical Documentation Specialist) certification, or/and CDIP (Certified Documentation Improvement Practitioner) certification
Preferred Qualifications:
- Associate and 5 years experience
- 5 years acute care
- Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, postacute care unit, or Emergency Department experience.
- 3 years o
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