AdventHealthClinical Documentation Specialist Full Time Days $3,000 Sign On $3,000 Relocation Assistance in
Clinical Documentation Specialist
Location Address: 1000 Waterman Way Tavares, Florida 32778
Top Reasons to Work at AdventHealth Waterman
Career Growth and Advancement Potential
Join a Faith Based, Non-Profit Healthcare Organization
Community Based Hospital Focused on Patient Care
You Will Be Responsible For:
Performs accurate and timely review of electronic health record to initiate work sheets on DRG payers for inpatient admissions.
Demonstrates the ability to analyze and identify areas of potential gaps representing opportunities for documentation improvement in order to reflect severity/complexity profile making an appropriate determination whether a physician clarification/query is required.
Possess the ability to formulate clinically credible documentation/ clarifications/queries; utilizing effective and appropriate communication options for physician follow up, which will occur in a timely manner.
Identifies the need and presence of “MCC” or “CC” for the DRG
Demonstrates efficiency in Guide (JATA) guidelines, software and accurate input of data into CDMP Trak. As well as, the ability to review archived cases and generate reports as needed.
What You Will Need:
Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication as well as strong interpersonal skills.
Knowledge of Pathophysiology and disease process
Working expertise in the use of Microsoft Word, Power-Point and Excel programs.
Proficient typing skills with the ability to accurately type >35 words per minute.
State of Florida RN License
Minimum 5 years of recent hospital experience
ICU, CCU, or strong Med/Surg. Experience preferred.
The CDS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness. This involves extensive record review, interaction with physicians, HIM professionals and nursing staff. Active participation in team meetings and education of staff in the CDMP® process is a key role.
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.