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Clinical Documentation Specialist II Non Licensed

Redmond Regional Medical Center

This is a Full-time position in Rome, GA posted November 11, 2021.

Description

Clinical Documentation Specialist II  – AdventHealth Redmond

Location Address: 501 Redmond Rd, NW, Rome 30165

Top Reasons To Work At AdventHealth Redmond

Faith based organization

Employee Referral Program

Located in the foothills of the North Georgia Mountains

Co-workers that feel like family

Educational Reimbursement Plans

What You Will Be Responsible For:

  • Demonstrates extending the healing ministry of Christ, through behavioral whole care standards of love me, make it easy, own it and keep me safe to every person they meet.  Delivers exceptional care and strives for excellence.  Committed to improving the health, prosperity and well-being of the communities we serve.  Uphold the highest standards, with integrity driving every decision made and every action taken. Guided by relentless stewardship in the management of resources entrusted to them.
  • Reviews concurrent medical record for 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 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 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.
  • Completes well-timed follow-up case reviews on all concurrent cases with priority given for resolution of those with clinical documentation clarifications.
  • 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.
  • Demonstrates competence by achieving an annual average of 90% on compliance audit scores
  • Proficient in formulating valid clarifications that are easily understood by physicians and other members of the medical team.
  • Accurately reconciles all cases in CDI.
  • Maintains a 97% physician response rate to all valid clarifications.
  • Assists in new hire orientation through precepting and mentoring.
  • Completion of educational project to be presented to CDI team yearly.
  • Performs other duties as assigned.

Qualifications

What You Will Need:

  • Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates 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.
  • Strong ability to organize/triage work and manage multiple priorities at once.

KNOWLEDGE AND SKILLS PREFERRED

  • Knowledge of clinical documentation requirements that identify clinical conditions or procedures. 
  • Coding background.
  • Knowledge of quality guidelines.

EDUCATION AND EXPERIENCE REQUIRED

  • Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
  • BSN or higher degree in healthcare related field, and 3 years of Clinical Documentation Specialist experience

EDUCATION AND EXPERIENCE PREFERRED:

  • MSN or Master or higher degree in a healthcare related field, and 3 years of Clinical Documentation Specialist experience

LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED

  • Current active State license as a Registered Nurse, Nurse Practitioner, Physician’s Assistant or an unlicensed physician who has graduated from a medical school that is listed in the World Directory of Medical Schools (World Directory) as meeting eligibility requirements for its graduates to apply to the Educational Commission for Foreign Medical Graduates (ECFMG) for ECFMG Certification and examination at the time of graduation and,
  • CCDS (Certified Clinical Documentation Specialist) certification, or/and CDIP (Certified Documentation Improvement Practitioner) certification
  • In lieu of above certification, BSN or higher degree and 3 years of experience

Job Summary:

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.

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.


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