Clinical Documentation Specialist Full Time
Req #: 18002936
Location: Tampa, FL
Job Category: Quality/Clinical Effectiveness
Organization: Florida Hospital Tampa
Potential Referral Bonus: $
Florida Hospital Tampa
Our hospital has celebrated many firsts in Tampa’s health care history since we opened our doors in 1968. Today, more than four decades later, Florida Hospital Tampa continues to offer innovative medicine as we elevate health care in the Tampa Bay region.
At Florida Hospital Tampa, our diverse clinical specialties provide world-class health care to our patients. We offer the most trusted, expert care in key specialties including cardiovascular care, neurosciences, orthopedics, women's health, cancer and surgery. Our skilled surgeons not only utilize minimally invasive and robot-assisted procedures, but they are also leaders in improving these advanced techniques
You will be responsible for:
- Demonstrates, through behavior, Integrity, Compassion, Balance, Excellence, Stewardship, and Teamwork
- Reviews concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies.
- Completes accurate and timely record review to ensure the integrity of documentation compliance. Completes accurate and concise input of data into CDMP Trak resulting in accurate metrics provided by the CDMP program. Understands and supports CDMP documentation strategies (upon completion of training) and continues to educate self and team members using educational tools, videos and provided WebEx’s.
- Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping reimbursement considerations in balance with regulatory compliance. Initiates/formulates CDMP severity worksheets and clinically credible clarifications for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other medical staff.
- 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 attending physicians, allied health practitioners, nursing, and care management. This includes quarterly 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 Task Force meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified by the CDI group.
- Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.
- Performs other duties as assigned.
What will you 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, Nurse Practitioner, or Physician’s Assistant.
- 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)
- Coding background (Preferred)
- BSN, MSN (Preferred)
- Clinical Documentation Specialist experience(Preferred)
- CCDS (Certified Clinical Documentation Specialist) certification (Preferred)