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Clinical Documentation Integrity Specialist - Registered Nurse

Medical Records / Health Info Mgmt
Adventist Health System Corporate Office

If you want to be a part of a place that provides nothing less than extraordinary compassionate care, then Adventist Health System is the place for you!

We are currently seeking qualified candidates for a Clinical Documentation Integrity Specialist position that will be based in our Office of Clinical Effectiveness department. This position is based at our corporate office in Altamonte Springs, FL.

This position provides the opportunity to be an expert in clinical documentation requirements. The CDS will assist in the evaluation of medical record documentation in the clinical setting and provide recommendations to improve existing documentation.The CDS works collaboratively with AHS CDS nurses and other professionals to validate that the medical record conveys accurate, concise data that reflects severity of illness and intensity of service to ensure coding accuracy in the delivery of patient care.

Specific job duties include:
  • Leads out in educational initiatives via web or onsite; educating CDS leaders and end-users through training and implementation of CDS software enhancements and revisions promoting advanced CDS practice
  • Provides clinical documentation expertise when working with CDS, CM, physician and coding staff to improve documentation specificity for working DRG/ final coded DRG assignment.
  • Develops, communicates, and enforces corporate policies and procedures consistent with organization and governmental standards of compliance.
  • Collaborates and contributes in the development of strategic initiatives that provide opportunities to improve documentation as directed.
  • Provides facility with ongoing support for CDI system enhancements.
  • Leads facilities through system updates and testing for all Clinical Documentation software.
  • Collaborates with hospital leadership, physicians, end-users, vendors and associates to develop and deploy electronic applications or new functionality.
  • Participates in training classes to stay current with regulatory changes specific to CDI
  • Leads team meetings, project meetings, and other meetings when requested.
  • Collects and analyzes data to provide reports and make appropriate recommendations for process improvements.
  • Identifies and acts upon opportunities for continuous improvement. Summarizes the meaning of new strategic directions for the work group and sets objectives. Demonstrates personal commitment to change through actions and words. Encourages others to support change through times of stress and uncertainty.
  • Works collaboratively with AHS providers, AIT, AHS/Clinical Effectiveness staff and other Revenue Cycle team members in the development and integration of processes to streamline workflow and increase productivity

Experience Requirements:
  • 3-5+ years’ experience in an acute care clinical facility
  • 3+ years’ experience in Clinical Documentation Management (CDI)
  • 2+ years’ experience in educating / training adult learners

Educational Requirements:
  • College Degree (BA, BS, BSN) in a field of study such as business, IS, or healthcare related area

Knowledge and Skills Requirements:
  • Current knowledge of CDI processes
  • Understands the rules of compliant documentation to serve as a resource to Clinical Documentation Specialist (CDS) nurses, physicians and other members of the disciplinary team.
  • Ability to efficiently and concurrently review medical record and identify opportunities to assist physicians in improving documentation.
  • Knowledge & expertise in documentation strategies for developing training materials and rollout of CDS education initiatives.
  • Ability to create materials & instruct educational training to varied groups of adult learners in various settings

If this position sounds like a great match for your skills set and experience, please apply online now!

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